PHR-English-Adult
Health Information Form-for Adults
A. Identification B. Emergency Contacts
Name (Last) (First) (Middle)In Case of Emergency, Notify: Primary Contact Name (last) (First) (Middle)
Maiden Name
Primary AddressRelationship
CityStateZipCountryAddress
Alternate AddressCityStateZip CodeCountry
CityStateZip CodeCountryHome Phone Work Phone
Home PhoneWork PhoneCell PhoneEmail Address
Cell PhoneEmail Address
Date of BirthSex:
FORMCHECKBOX Male FORMCHECKBOX FemaleIn Case of Emergency, Notify: Secondary Contact
HeightWeightEye ColorHair ColorName (last)Name (middle)Name (first)
RaceBirthmark/ScarsRelationship
Blood/RH TypeSpecial ConditionsMarital StatusAddress
OccupationCityStateZip CodeCountry
Company NameHome PhoneWork Phone
CityStateZip CodeCountryCell PhoneEmail Address
Phone NumberLanguages SpokenIn Case of Emergency, Notify: Medical Contact
Primary Health Insurance Carrier
Secondary Health Insurance CarrierPolicy Number
Policy NumberDoctor (Indicate Specialty)
Phone Number
Dentist
Telephone Number
Pharmacy
Telephone Number
C. Healthcare Provider
Healthcare Provider SpecialtyPrimary Care Physician
FORMCHECKBOX Yes FORMCHECKBOX NoPhoneEmergency Phone No.(after hours)
NameEmail Address
Group or AssociationFax
AddressWeb Address/URL
CityStateZip CodeCountry
Healthcare Provider SpecialtyPrimary Care Physician
FORMCHECKBOX Yes FORMCHECKBOX NoPhoneEmergency Phone No.(after hours)
NameEmail Address
Group or AssociationFax
AddressWeb Address/URL
CityStateZip CodeCountry
Healthcare Provider SpecialtyPrimary Care Physician
FORMCHECKBOX Yes FORMCHECKBOX NoPhoneEmergency Phone No.(after hours)
NameEmail Address
Group or AssociationFax
AddressWeb Address/URL
CityStateZip CodeCountry
Healthcare Provider SpecialtyPrimary Care Physician
FORMCHECKBOX Yes FORMCHECKBOX NoPhoneEmergency Phone No.(after hours)
NameEmail Address
Group or AssociationFax
AddressWeb Address/URL
CityStateZip CodeCountry
D. Insurance Providers
Insurance Provider TypeE-mail AddressFax
Company NameWeb Address/ URL
AddressPrimary Insured Person-NameSocial Security No.
City StateZip CodeCountryName of Employer
Contact NamePhoneAddress
Identification-Group NumberMember(ID) NumberCity StateZip CodeCountry
Contact Information-PhoneEmergency Phone No.(after hours)Phone Number
Insurance Provider TypeE-mail AddressFax
Company NameWeb Address/ URL
AddressPrimary Insured Person-NameSocial Security No.
City StateZip CodeCountryName of Employer
Contact-NamePhoneAddress
Identification-Group NumberMember(ID) NumberCity StateZip CodeCountry
Contact Information-PhoneEmergency Phone No.(after hours)Phone Number
Insurance Provider TypeE-mail AddressFax
Company NameWeb Address/ URL
AddressPrimary Insured Person-NameSocial Security No.
City StateZip CodeCountryName of Employer
Contact-NamePhoneAddress
Identification-Group NumberMember(ID) NumberCity StateZip CodeCountry
Contact Information-PhoneEmergency Phone No.(after hours)Phone Number
E. Legal Documents/Medical Directives
FORMCHECKBOX Living Will FORMCHECKBOX Durable Power of Attorney for Healthcare
FORMCHECKBOX Power of Attorney Fax
Document Location (Physical Location)Contact (Name of person who has access to the document)
Location Name (for example Bank of America)Address
AddressCity StateZip CodeCountry
City StateZip CodeCountryContact Information
Legal Representative (Name of person who you have assigned legal authority)
Home PhoneCellular Phone
AddressPagerE-mail Address
City StateZip CodeCountryWork PhoneWork E-mail Address
Contact InformationFax
Home PhoneCellular PhoneDate Filed
PagerE-mail AddressOrgan Donation:
Work E-mail AddressWork PhoneOrgan Donor
FORMCHECKBOX Yes FORMCHECKBOX No State Where Registered
FORMCHECKBOX Living Will FORMCHECKBOX Durable Power of Attorney for Healthcare
FORMCHECKBOX Power of AttorneyFax
Document Location(Physical Location)Contact ( Name of person who has access to the document)
Location Name (for example Bank of America)Address
AddressCity StateZip CodeCountry
City StateZip CodeCountryContact Information
Legal Representative (Name of person who you have assigned legal authority)
Home PhoneCellular Phone
AddressPagerE-mail Address
City StateZip CodeCountryWork PhoneWork E-mail Address
Contact InformationFax
Home PhoneCellular PhoneDate Filed
PagerE-mail AddressOrgan Donation:
Work E-mail AddressWork Phone Organ Donor
FORMCHECKBOX Yes FORMCHECKBOX No State Where Registered
F. Medical History(Check appropriate)
FORMCHECKBOX Acquired Immunodeficiency Sndrome(AIDS) or HIV Positive:Date of Onset FORMCHECKBOX High Blood PressureDate of Onset
FORMCHECKBOX
Arthritis FORMCHECKBOX
Hypoglycemia
FORMCHECKBOX
Asthma FORMCHECKBOX
Jaundice
FORMCHECKBOX
Bronchitis FORMCHECKBOX
Kidney Disease
FORMCHECKBOX
Cancer FORMCHECKBOX
Low Blood Pressure
FORMCHECKBOX
Chlamydia FORMCHECKBOX
Mental Retardation
FORMCHECKBOX
Diabetes FORMCHECKBOX
Pain or Pressure in Chest
FORMCHECKBOX
Dizziness FORMCHECKBOX
Palpitations
FORMCHECKBOX
Emphysema FORMCHECKBOX
Periods of unconsciousness
FORMCHECKBOX
Epilepsy FORMCHECKBOX
Rheumatic Fever
FORMCHECKBOX
Eye Problem FORMCHECKBOX
Rheumatism
FORMCHECKBOX
Fainting FORMCHECKBOX
Seizures
FORMCHECKBOX
Frequent or Severe Headaches FORMCHECKBOX
Shortness of Breath
FORMCHECKBOX
Glaucoma FORMCHECKBOX
Stomach Liver or Intestinal Problems
FORMCHECKBOX
Gonorrhea FORMCHECKBOX
Syphilis
FORMCHECKBOX
Hearing Impairment FORMCHECKBOX
Tuberculosis
FORMCHECKBOX
Heart Condition FORMCHECKBOX
Tumor
FORMCHECKBOX
Hemodialysis FORMCHECKBOX
Thyroid Problems
FORMCHECKBOX
Herpes FORMCHECKBOX
Urinary Tract Infection
FORMCHECKBOX
High Blood Cholesterol FORMCHECKBOX
Other
G. Infectious Diseases
Disease
AgeDateRemarks
Chicken Pox
Hepatitis
Measles
Mumps
Pertussis /Whooping Cough
Pneumona
Polio
Rubella
Scarlet Fever
Other
H. ImmunizationsBooster 1Booster 2Booster 3
Immunization forAgeDateAgeDateAgeDate
Diptheria
Hepatitis B
Measles
Mumps
Pertussis/Whooping Cough
Polio
Rubella
Smallpox
Tetanus
Tuberculosis
Typhoid
Other
I. Allergies/Drug Sensitivities
Allergy/Sensitivity Type (include medications foods environmental or other)ReactionDate last Occurred Treatment
J. Family Member History
MotherFatherSibling(s)
Grandparent(s)
Children
Enter ages of relatives
If deceased, indicate age and cause of death
Check all items that apply for their present state of health or any illnesses they have had
Alcoholism
Arthritis
Asthma
Cancer
Diabetes
Emphysema
Glaucoma
Heart Condition
Hemodialysis
Hepatitis
High Blood Cholestrol
High Blood Pressure
Kidney Disease
Mental Retardation
Rheumatic Fever
Seizures
Smoking
Stomach Liver or Intestinal Problems
Stroke
Thyroid Disorders
Tuberculosis
Tumor
Other
K. Lifestyle
FORMCHECKBOX AlcoholDrink(s) Per WeekNumber of Years
FORMCHECKBOX SmokingPack(s) Per DayNumber of Years
FORMCHECKBOX ExerciseType(s) of Exercise
Days Per Week
L. Health Log (Noninfectious major illnesses. Include pregnancies and childbirth)
Date DiagnosedDoctorNature of Health ProblemsAge at OnsetCondition StatusRemarks (Such as, medications, special tests, x-rays, length of hospital stay, surgery and so on)
M. MedicationsNote: Include all prescription medications, (such as nitroglycerin) over-the-counter medications (taken on a regular basis), vitamin supplements, and herbal remedies
DateMedication / DosageFrequency
N. Doctor Visits
DateDoctorReasonDiagnosis
O. Hospitalizations
Hospitalization Type (includes emergency room visits)Diagnosis
Admission DateDischarge Date
Doctor
Hospital
ReasonComplications
Hospitalization Type (includes emergency room visits)Diagnosis
Admission DateAdmission Date
Doctor
Hospital
ReasonComplications
Hospitalization Type (includes emergency room visits)Diagnosis
Admission DateDischarge Date
Admission Date
Doctor
Hospital
ReasonComplications
P. Surgeries
DateDoctorResults
Hospital
Surgical Procedure
DescriptionComments
DateDoctorResults
Hospital
Surgical Procedure
DescriptionComments
DateDoctorResults
Hospital
Surgical Procedure
DescriptionComments
Q. Lab or Imaging (Examples: X-ray, MRI, Mammogram)
Test TypeDateTest TypeDate
Requesting DoctorAdministered byRequesting DoctorAdministered by
ReasonReason
ResultResult
Test TypeDateTest TypeDate
Requesting DoctorAdministered byRequesting DoctorAdministered by
ReasonReason
ResultResult
R. Medical Devices (Examples: pacemaker, insulin pumas, breathing devices)
Device TypeDoctorDevice TypeDoctor
HospitalDateHospitalDate
ReasonReason
S.Physical/Occupation Therapy
Therapy TypeStart DateStop DateFrequencyTherapist
T. VISION
Date of VisitPhysicianDate of VisitPhysician
Vision RXVision RX
Date of VisitPhysicianDate of VisitPhysician
Vision RXVision RX
U. Dental Health
Date of VisitDentistProblemsResolution
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