medical records - printables by design · 2018. 10. 27. · cholesterol name month day cholesterol...

Medical Records

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Blood Pressure

NAME MONTH

Day Time Systolic Diastolic Pulse Comments

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Blood Pressure Tracker

Blood Sugar

NAME MONTH

Day Breakfast Lunch Dinner Bedtime Comments

Before After Before After Before After

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Monthly Sugar Level

Cholesterol

NAME MONTH

Day Cholesterol HDL LDL Triglycerides Comments

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Monthly Average:


Monthly Cholesterol Level

Dental Visits

Appointment Tracker

NAME: Date: Time:

Location:

Dentist:

Phone Number:

Reason for Visit:

Treatment -Notes:

Cancelled : □ Reschedule Date: Follow - Up : Complete: □

NAME: Date: Time:

Location:

Dentist:

Phone Number:

Reason for Visit:

Treatment -Notes:


NAME: Date: Time:

Location:

Dentist:

Phone Number:

Reason for Visit:

Treatment -Notes:


NAME: Date: Time:

Location:

Dentist:

Phone Number:

Reason for Visit:

Treatment -Notes:



Doctor Visits

Appointment Tracker

NAME: Date: Time:

Location:

Physician:

Phone Number:

Reason for Visit:

Treatment -Notes:


NAME: Date: Time:

Location:

Physician:

Phone Number:

Reason for Visit:

Treatment -Notes:


NAME: Date: Time:

Location:

Physician:

Phone Number:

Reason for Visit:

Treatment -Notes:


NAME: Date: Time:

Location:

Physician:

Phone Number:

Reason for Visit:

Treatment -Notes:



Eye Exams

Appointment Tracker

NAME: Date: Time:

Location:

Optometrist:

Phone Number:

Reason for Visit:

Treatment -Notes:


NAME: Date: Time:

Location:

Optometrist:

Phone Number:

Reason for Visit:

Treatment -Notes:


NAME: Date: Time:

Location:

Optometrist:

Phone Number:

Reason for Visit:

Treatment -Notes:


NAME: Date: Time:

Location:

Optometrist:

Phone Number:

Reason for Visit:

Treatment -Notes:



Glucometer

NAME

Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Before After Before After Before After Before After Before After Before After Before After

Breakfast

Lunch

Dinner

Bedtime

Weekly Average



Breakfast

Lunch

Dinner

Bedtime

Weekly Average



Breakfast

Lunch

Dinner

Bedtime

Weekly Average



Breakfast

Lunch

Dinner

Bedtime

Weekly Average

Monthly Average


Glucometer Reading Tracker

Insulin

NAME MONTH

Day Time Blood Sugar Level Insulin Type Amount Injection Site

AM PM

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Insulin Shot Record

Lab Test

NAME:

YEAR:

Test Result Tracker

TEST NAME: Date: Time:

Location:

Conducted by:

Results Date:

Diagnosis:

Treatment -Notes:



Location:

Conducted by:

Results Date:

Diagnosis:

Treatment -Notes:



Location:

Conducted by:

Results Date:

Diagnosis:

Treatment -Notes:



Location:

Conducted by:

Results Date:

Diagnosis:

Treatment -Notes:



Medical Contacts

NAME: NAME:

Specialty: Specialty:

Address: Address:

Phone #: Phone #:

Fax #: Fax #:

Website: Website:

NAME: NAME:


Address: Address:

Phone #: Phone #:

Fax #: Fax #:

Website: Website:

NAME: NAME:


Address: Address:

Phone #: Phone #:

Fax #: Fax #:

Website: Website:

NAME: NAME:


Address: Address:

Phone #: Phone #:

Fax #: Fax #:

Website: Website:

Doctor Contacts


Medical Contacts

FAMILY PHYSICIAN

Name:

Address:

Phone Number:

Fax Number:

Office Hours:

Website:

PEDIATRICIAN

Name:

Address:

Phone Number:

Fax Number:

Office Hours:

Website:

OB/GYN

Name:

Address:

Phone Number:

Fax Number:

Office Hours:

Website:

DENTIST

Name:

Address:

Phone Number:

Fax Number:

Office Hours:

Website:

OPTOMETRIST

Name:

Address:

Phone Number:

Fax Number:

Office Hours:

Website:

Doctor Contacts


Medical Details

Full Name:

Address:

Home Phone: Cell Phone:

Date of Birth: Blood Type:

Emergency Contact: Phone No:

Emergency Contact: Phone No:

Hospital: Phone No:

Primary Physician: Phone No:

Pharmacy: Phone No:

Dentist: Phone No:

Optometrist: Phone No:

Orthodontist Phone No:

Food Allergies:

Medical Allergies:

Supplements:

Surgeries: Year:

Year:

Year:

Year:

Year:

Current: Medication Dosage Frequency Condition

Medical Information


Medical Insurance

HEALTH INSURANCE PROVIDER

Company:

Address:

Policy Number:

Office Phone:

Cell Phone:

Fax Number:

Issue Date:

Expire Date:

Reference Number:

Group ID:

Agent:

Email:

NOTE:

DENTAL INSURANCE PROVIDER

Company:

Address:

Policy Number:

Office Phone:

Cell Phone:

Fax Number:

Issue Date:

Expire Date:

Reference Number:

Group ID:

Agent:

Email:

NOTE:

LIFE INSURANCE PROVIDER

Company:

Address:

Policy Number:

Office Phone:

Cell Phone:

Fax Number:

Issue Date:

Expire Date:

Reference Number:

Group ID:

Agent:

Email:

NOTE:

Insurance Details


Medical Notes


Medical Information

Medication Refills

NAME: Allergies:

Medication: Reason:

Physician: Phone #:

Pharmacy: Phone #:

Fill Date: Last Refill Date:

Refills: Refill #: NOTES:

NAME: Allergies:

Medication: Reason:

Physician: Phone #:

Pharmacy: Phone #:



NAME: Allergies:

Medication: Reason:

Physician: Phone #:

Pharmacy: Phone #:



NAME: Allergies:

Medication: Reason:

Physician: Phone #:

Pharmacy: Phone #:



Refill Tracker


Prescriptions

NAME

Medication Condition Time Frame Cost End Result/Notes

Start Date End Date


Prescription Tracker

Questionnaire

\

Pre – Doctor Concerns

NAME: Date: Time:

Location:

Physician:

Phone Number:

Reason for Visit:

Current Medications

Symptoms

Questions /Concerns


Seizures

NAME

Date Time Pre - Activity Duration Injuries Comments

Y N


Seizure Tracker

Sodium Intake

NAME

Date Time Meal/Food Sodium Comments


Sodium Intake Tracker

Surgical Record

Medical Procedures

NAME: Date: Time:

Location:

Surgeon:

Phone Number:

Procedure:

Treatment -Notes:


NAME: Date: Time:

Location:

Surgeon:

Phone Number:

Procedure:

Treatment -Notes:


NAME: Date: Time:

Location:

Surgeon:

Phone Number:

Procedure:

Treatment -Notes:


NAME: Date: Time:

Location:

Surgeon:

Phone Number:

Procedure:

Treatment -Notes:



Temperature Log

NAME MONTH

Day Hourly Temperature

7:00 8:00 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00

1

2

3

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Fever Tracker

Vitamins

NAME MONTH

Date S M T W TH F S Vitamin/Supplement Frequency Dose Time


Monthly Vitamin Record

Allergies

NAME EPI - Pen Location

ALLERGY

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Snif

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Swe

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Dia

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Cra

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MEDICATION


Allergy Record

Dental Visits

NAME

|

Date Time Dentist Location Contact Number Reason For Visit

AM PM

NOTES


Appointment Tracker

Doctor Visits

NAME

|

Date Time Physician Location Contact Number Reason For Visit

AM PM

NOTES


Appointment Tracker

Eye Exams

NAME

|

Date Time Optometrist Location Contact Number Reason For Visit

AM PM

NOTES


Appointment Tracker

Fibromyalgia

NAME

|

Date Time of Pain Duration Pain Scale Pain Location Medication Taken Time Taken Comments

(1-10)

NOTES


Pain Tracker

Lab Test

NAME

|

Date Type of Test Place of Testing Performed By Diagnosis Treatment Prescribed Follow - Up


Test Result Tracker

Medical Expenses

NAME YEAR

|

Bill Date Billed From Services Rendered Amount Due Ins. Payments Out of Pocket Balance Due

TOTALS


Expense Record

Medication Refills

NAME YEAR

|

Medication Physician Phone # Refills Pharmacy Phone # Fill Date Last Fill Date


Refill Tracker

Medication

NAME YEAR

|

Medication Dose Frequency Special Instructions Purpose Physician Refills Pharmacy #


Medication Tracker

Medication Side Effects

Medication Purpose Side Effects


Surgical Record

NAME

|

Date Hospital/Surgeon Procedure Rehabilitation Prescribed Medication


Medical Procedures

Vaccine Record

NAME

|

Vaccine Type Date Age Site Lot # Mfr. Vaccinator Cost Note


Immunizations

medical records - printables by design · 2018. 10. 27. · cholesterol name month day cholesterol...

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