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ADULT MEDICAL HEALTH HISTORY FORM PATIENT INFORMATION Last Name: Preferred Name: Date of Birth:First Name//Middle NameGender:Sex assigned at birth:Home Phone:Cell Phone:Work Phone:Mailing Address:City:State:Email
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How to fill out adult personal health record

01
Gather personal information such as full name, date of birth, and contact details.
02
List all current medications including prescription and over-the-counter drugs.
03
Document any known allergies and adverse reactions to medications.
04
Record medical history including past illnesses, surgeries, and hospitalizations.
05
Include family health history noting any hereditary conditions.
06
Note lifestyle factors such as diet, exercise, and smoking or alcohol use.
07
Update regularly with any new health information or changes in status.

Who needs adult personal health record?

01
Adults managing chronic health conditions.
02
Individuals who frequently visit multiple healthcare providers.
03
People who want to keep track of their health history and medications.
04
Caregivers and family members supporting an adult's healthcare.
05
Anyone preparing for medical appointments or procedures.
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An adult personal health record (PHR) is a tool that allows individuals to manage and store their health information in one location, helping them keep track of their medical history, medications, and other health-related data.
Generally, individuals who wish to maintain a comprehensive record of their personal health information are encouraged to file an adult personal health record. There may be specific requirements depending on healthcare providers or insurance companies.
To fill out an adult personal health record, individuals need to collect their medical history, including past diagnoses, treatments, medications, allergies, immunization records, and contact information for healthcare providers. This information is then entered into the PHR template.
The purpose of an adult personal health record is to empower individuals to take charge of their health by having quick access to their medical information, which can facilitate better communication with healthcare providers and enhance the quality of care.
The information that must be reported on an adult personal health record includes personal identification details, medical history, immunization records, medications currently being taken, allergies, family health history, and contact information for healthcare providers.
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