MY PERSONAL HEALTH RECORD (PHR) STARTER KIT
Premier Medical Group of Mississippi is pleased to offer a Starter Kit for patients interested in recording their personal health journey. As patient travel more and more across provider lines and across geographic locations, our hope is that the PHR Starter Kit will be a rich, and potentially lifesaving, source of health information.
This Starter Kit is intended to provide a basic healthcare history outline, from which a concise personal health record may be developed. Our philosophy is that optimal healthcare is directly related to a caregiver’s ability to have ready access to accurate, pertinent healthcare information.
With this in mind, the PHR Starter Kit begins with the following questionnaire designed to provide any clinician with basic information needed to evaluate a patient:
Legal Name_____________________________________________________________
Address_________________________________________________________________
Home Phone_____________ Cell Phone______________Work Phone_____________
E-Mail Address__________________________________________________________
Insurance and Medicare Information_____________________________________________________________
________________________________________________________________________
Past Medical History
- Hypertension (high blood pressure)
- Diabetes
- Hyperlipidemia (elevated cholesterol or triglycerides)
- Coronary heart disease
- Congestive heart failure
- Asthma
- COPD (emphysema)
- Other (List)____________________________________________________
Past Surgical History
Procedure Surgeon Facility Date- _______________________________________________________________
- _______________________________________________________________
- _______________________________________________________________
- _______________________________________________________________
- _______________________________________________________________
Allergies to any substance_______________________________________________________________
Social History
o
Alcohol usage o Yes o No o Amount___________________o
Tobacco usage o Yes o No o Type________ o Amount_______o
History of substance abuse/illicit drug use______________________________Advance Directive (Living Will, Medical Power of Attorney)
o Yes o NoFamily History
|
Relationship |
Age |
Living or Expired? (Circle) |
Medical Problems |
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Mother |
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Father |
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Sibling (M/F) |
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Sibling (M/F) |
My Personal Medication List (including over-the-counter medications and supplements)
|
Medication |
Dosage |
Directions |
Prescribing Doctor |
Number of Refills |
Preventive Health
|
Procedure |
Date |
Physician |
Results |
Follow-Up Needed |
|
Pap Smear |
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Mammogram |
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Colonoscopy |
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Bone Density |
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Vaccinations: |
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*Pneumonia |
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* Flu |
Annual | |||
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*Tetanus |
Every 10 Years | |||
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*Hepatitis |
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*Shingles |
||||
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*Other |
Prior Hospitalizations Not Listed in Past Surgical History
|
Facility |
Date |
Diagnosis |
Major Studies Performed
|
Procedure |
Date |
Facility |
Results |
|
CT scan (list body part) _________________________ |
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MRI scan (list body part) _________________________ |
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Echocardiogram |
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Stress Test/Nuclear Scan |
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Blood Transfusions |
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Other___________________ |
KNOW YOUR NUMBERS!
|
Total Cholesterol |
Number |
Date |
|
Number |
Date | |
|
HDL (good) |
Number |
Date |
|
Number |
Date | |
|
LDL (bad) |
Number |
Date |
|
Number |
Date | |
|
Triglyerides |
Number |
Date |
|
Number |
Date | |
|
A1C (average blood sugar) |
Number |
Date |
|
Number |
Date | |
|
Blood Pressure |
Sys/Dias |
Date |
|
Sys/Dias |
Date |
The most efficient way to maintain this information is by saving it on a word processor or on a computer. This allows you to edit and update your information easily and as needed.
Physician Diagnosis/Impression
_________________________________________________________________________
_________________________________________________________________________
Plan/Instruction:
o
Referral for testing_______________________________________________________o
Referral for consultation__________________________________________________o
Change in medications (specify)___________________________________________o
Diet/exercise (specify)___________________________________________________o
Other__________________________________________________________________
Premier Medical Group of Mississippi encourages the maintenance of your personal health record (PHR) using this handy documentation tool. We encourage you to take an active role in recording and participating in your health events, as YOU are the best source of your health information history. In addition, we urge you to feel free to modify this document, or Starter Kit, as there may be items not listed above which are specific to your healthcare situation. This is a record of YOU, documented by YOU and maintained by YOU!
