Personal Health Record Template

I have a lot of doctors.  A lot of doctors.  I’ve seen more than I can count and each time I go in, they ask me to fill out a new patient form.  Inevitably, the form does not have enough space to include all of my information.  And worse, I’ve already filled this form out in hundreds of other places.  So I decided to make my own form – a personal health record (PHR).

It mimics the same forms that you find at all doctors (minus current symptoms) and is a concise way to present my medical history.  With nearly 14 GB of health records, I can’t bring everything to an appointment.  So I store that information in a cloud-based system to pull up as needed at appointments and bring this document to check-in and for new doctors and hospitals.  This document gives me control over what I share in a way that current EHR (electronic health records) and serves as a great way for me to coordinate care.  Until EHRs are interoperable and in the patient’s control, this paper document is my best bet.

My doctors have been really receptive and appreciative of the detail and clarity.  And it helps me not only save time and energy in filling out yet another form, but in remembering things I may not recall in the moment (like all my meds or the exact date of a procedure).  It also helps anyone advocating for me to know the information that is important for my care.  I’m always updating and amending it to fit what I need and what I think will be most helpful to my providers.

I wanted to publish the document in the hopes other patients might have a template to create their own PHR.  I have taken out the majority of my personal information but you will see I have pages for specific issues that apply to me (like my mental health information and ECG results).  Other patients may not need to list as many things or may need to add other sections.  It is important to keep the main parts – allergies, diagnoses, medications, social determinants of health, surgeries, history of hospitalizations/procedures, onset of diagnoses, family history, and information of other providers – the items you will find on any intake form.

I hope this can help others.  I’d also love to learn what other patients think of it – would you add anything?  What do you use?

(clicking here will download a word file)

Personal Health Record Template

Let me know what you think and keep an eye out for my next post as I’ll get a version of my appointment primer up – a document I bring summarizing why I’m there that day.


2 Responses to Personal Health Record Template

  1. […] just posted my Personal Health Record (PHR) Template.  I bring in a PHR for my doctors to have my health history but I realized I also needed to bring […]

  2. AAC says:

    Thanks, It’s Helpful

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