Personal Health Record
This two-page handout is an easy-to-use personal health record to help patients keep track of information about their health care providers, medications, and questions for their health care team. It contains blank spaces for the patient to write down contact information for their primary and dental care providers, other caregivers, hospital, and pharmacy. It provides places to enter information about allergies, health goals, and questions for their doctor. The document includes a place for people to keep track of the name, dose, frequency, and reason for taking medications and supplements.
This document should not be modified, or reproduced, displayed, or distributed for commercial purposes or financial gain. It is available for use by any organization, by request to Aging and Disability Services (ADS) - The Area Agency on Aging for Seattle and King County. It may be modified, adapted, or built upon for publication if credit is given to Aging and Disability Services.
This translation was evaluated by a representative or group from the community for accuracy and cultural relevance.