Page 2 - Wellness-Nutrition-pamphlets-sample
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Exercise - Tracking Down Your Medical History
Putting Together a Medical Notebook Collecting your medical history is important to provide doctors with
a complete picture of your health. Where do you go to find all the
Contact Information Tab 3: My Medicine information needed to complete the forms? Use this exercise to plan
Name/address/ members of Your doctor needs the most up-to-date how to find your information.
your household. information on your medication. Preventing
Emergency contact information. drug, food, and medical condition interactions Who Will You Contact? What Are Your Questions?
Tab 1: My Health means you keep your medicine list up-to-
date. That includes tracking medicines you’ve Family History - Mother’s side
General Health Information stopped taking or caused your problems.
Social history - your job, marital status, Medications
children, smoking, drinking habits.
Medications Stopped
Medical conditions - check any you have and Family History - Father’s side
indicate the date when it started. You can fill Prescription Reorders
out details on each medical condition on a Supplements
separate page.
Immunizations - any vaccinations, tetanus Tab 4: My Doctor Visits X-rays, test results
shots, exposure to Tuberculosis.
Use the forms in this section to track your
Surgeries/hospitalizations - list any surgeries appointments, record any lab results from testing,
you had, the dates, reason, location, and results. and prepare and record results of your doctor
Family history - can show conditions that may visits. History of surgeries and
be hereditary. Appointments. treatments
Allergies Lab Log
Record any allergies you may have to foods, Doctor Visits
medications, and the environment.
Doctor records
Tab 5: My Wellness Plan
Tab 2: My Providers
Use this section to begin tracking things you do for
Record contact information for your physicians, your own health.
pharmacies and insurance companies.
Daily Food and Exercise Log Immunization records
Physician Information
Insurance Information Tab 6: Information from My Doctor
Pharmacy Information Place any information from your doctor in this
section.
