The Ultimate Personal Medical Information Form

Created & Provided by Prepare2Thrive.com / SailToSafety.com

Personal Information

Full Name:

Date of Birth:

Address:

Gender:
Male
Female
Other

Primary Care Doctor's Name:

Primary Care Doctor's Phone:

Primary Care Doctor's Address:

Emergency Contact Name:

Emergency Contact Phone:

Relationship to Emergency Contact:

Insurance Information (Provider, Policy Number):

Additional Notes:

Medication History

Current Medications:

Over-the-counter Medications and Supplements:

Immunization Record

Date of Last Tetanus Shot:

Date of Last Flu Shot:

Other Vaccinations:

Special Needs and Considerations

Mobility Needs:

Vision or Hearing Impairments:

Cognitive or Developmental Disabilities:

Behavioral Health Concerns:

Additional Notes

Additional Notes:

Personal Health History

Please check all conditions that apply:

Cardiovascular		Respiratory
Hypertension (High Blood Pressure)	Angina (Chest Pain)	Asthma	COPD (Chronic Obstructive Pulmonary Disease)
High Cholesterol	Heart Attack	Sleep Apnea	Pulmonary Embolism
Stroke	Heart Failure	Chronic Bronchitis	Tuberculosis
Endocrine/Metabolic		Gastrointestinal
Diabetes	Thyroid Disorders	GERD (Reflux/Heartburn)	Ulcers
Obesity	Gout	Liver Disease	Gallbladder Disease
Metabolic Syndrome	Osteoporosis	Irritable Bowel Syndrome	Crohn’s Disease/Colitis
Neurological		Genitourinary
Seizures	Migraines	Kidney Stones	Urinary Tract Infections
Dementia/Alzheimer’s	Parkinson’s Disease	Prostate Problems	Incontinence
Multiple Sclerosis	Neuropathy	Kidney Disease	Sexually Transmitted Diseases
Psychiatric		Hematologic/Immunologic
Depression	Anxiety	Anemia	Bleeding Disorders
Bipolar Disorder	Schizophrenia	Leukemia	Lymphoma
PTSD (Post-Traumatic Stress Disorder)	Substance Abuse	HIV/AIDS	Autoimmune Disorders
Other Conditions

Past Surgical History

Have you had any previous surgeries?
Yes
No
(If yes, please provide details below)

1. List of Previous Surgeries:

Date	Type of Surgery	Reason/Diagnosis	Hospital/Clinic	Surgeon (if known)
________	____________________	___________________	____________________	___________________
________	____________________	___________________	____________________	___________________
________	____________________	___________________	____________________	___________________
________	____________________	___________________	____________________	___________________
________	____________________	___________________	____________________	___________________

(Use additional pages if necessary)

2. Complications or Issues Related to Past Surgeries:

No known complications
Yes, specify below:

The Ultimate Personal Medical Information Form

Created & Provided by Prepare2Thrive.com / SailToSafety.com

Personal Information

Allergy Information

1. Latex Allergy

2. Medication Allergies

3. Food Allergies

4. Environmental Allergies

5. Other Allergies

Additional Details