Getting Started

Find Resources

  • Download “Personal Health Record Guidelines” (see below)
  • Download templates available for
    • Emergency (see below)
    • Comprehensive ( particularly helpful after an emergent event or seeing a new provider)
  • Choose either electronic or write-in template (see below)
  • Sources of information may include your physician(s), contact medical records department(s), family

Paper template

  • Simply fill in the fields with appropriate information. See below for “suggestion entries”.
  • Each page should have name and date of birth

Electronic template

  • Download onto either your computer or the computer of someone you trust with your information
  • “Save” frequently
  • At the top of document, replace “(name)”, “(date of birth)” and dates for “created” and “updated” with appropriate information.
  • To move between the header (where name is) and the body of the document, double click in the area in which you want to work
  • Click your mouse into appropriate fields and type. The fields will expand to fit the information you provide. To use the right side of the field either “tab” over or use an arrow key.
  • The field titled “Data” is designed to allow for additional fields as needed. “Copy & paste” to duplicate. Simply replace the title “Data” with appropriate new title
  • You may want to consider re-naming your document each time changes are made to allow viewing of previous entries. Suggested title “(name) PHR (date)”. Changing the date each time allows easy recognition of various entries.

Make your information available

  • In your house have information easily visible for 1st e.g. on refrigerator, bright colored paper, hanging on a “command” hook, etc
  • In your wallet – keep information near your driver’s license.
  • Share this information with family, friends, medical providers.


Suggested Entries

Personal Information

  • Name and DOB (date of birth), address, phone/email – self explanatory
  • Who to contact – who do you want notified in event of emergency or hospitalization?
  • DNR (Do Not Resuscitate) – Indicate if you have legal document and what it states. A hard copy is preferred. Be sure it is signed by the physician otherwise it is invalid.
  • Note: DNR is a separate document from your Living Will or Power of Attorney for Healthcare. DNR is often provided by your primary care physician.
  • Insurance – name, policy number, in whose name is the policy, phone number
  • DPOA (Durable Power of Attorney) for healthcare. If you have named someone to speak for your medical concerns in the event you cannot, who is it and how can this person(s) be contacted. This is not financial power of attorney.

Allergies and Reactions

  • List life-threatening (e.g. closes off throat) and intolerances (e.g. severe nausea).
  • Explain the reaction to each item
  • List items separately
  • What to list: medication, foods, additives, latex, environmental, . . .


  • Prescription
  • Non-prescription (vitamins, supplements, herbals, over the counter for pain)
  • Inhalers, creams, eye drops, insulin, birth control pills
  • List them ALL!
  • Include
    • Dose (typically listed as “mg.”, “Gm”, or “mcg”, “units”)
    • How many times a day
    • Time of day – important to ensure proper instruction and administration of medication if someone else is giving you your medications

Devices / Implants

  • Heart pacemakers, defibrillators,
  • Any implant
  • Include brand / manufacturer / date


  • Seasonal flu shots
  • Pneumonia
  • Tetanus, Pertussis
  • Shingles
  • Hepatitis
  • Any
  • Include date

Medical Conditions

  • List current and previous medical conditions
  • What should you include? More is better. A healthcare professional can help you sort out your list
  • Include date of diagnosis (if known). Consider adding who / where diagnosis – particularly “bigger” diagnoses


  • List all surgeries, procedures, and biopsies
  • ALL surgeries – even as infant or what seems insignificant
  • Include date (if known)
  • For larger or more complicated cases, include where and surgeon

Social History

  • Smoking: Yes? No? How many years? How many packs/day? When did you quit? Never a smoker?
  • Alcohol: Be specific in type, amount, frequency. Avoid terminology such as “socially”, “occasionally”. These terms are too ambiguous.
  • Drugs: Marijuana included. Be honest. It’s for your safety.
  • Caffeine: what and how much per day
  • Education / employment: What level of education and what type of work.
  • Marital status – optional

Tests / Hospitalizations

  • Hospitalized where and for what
  • Radiologic – e.g. x-ray, CT scan, MRI
  • Lab / pathology / biopsy – e.g. CBC, chemistry, thyroid, A1C, specific testing
  • Cardiac – e.g. EKG, Echocardiogram, Stress test, Catheterization, any cardiac procedure. It is very helpful if you have the actual report available. Otherwise it is helpful to know where, when, and who performed the testing.
  • Pulmonary – e.g. pulmonary function test
  • Sleep study – Results. Do you use a device?
  • Other Diagnostics – e.g. EEG, EMG, others
  • Preventive -e.g. colonoscopy, mammogram, bone density, PSA . . .

Family History

  • Provide what you know
  • Parents, Siblings, Grandparents, Aunts, Uncles, Children
  • Include age of death if applicable
  • Focus on cardiovascular, diabetes, cancer, mental illness, neurological disorders

  Medical Providers

  • There are two sections. One for “current” – those you currently see and another for “previous” – those you’ve seen in the past and may have some pertinent records
  • List all that you see or have seen
  • Name, group name, address, phone, (fax)
  • Primary care, cardiologist, neurologist, hematologist, oncologist, urologist, surgeon, gynecologist, podiatrist, dental, optometrist, ophthalmologist, chiropractor, . . . .
  • Knowing your date of last visit, particularly with specialists can be helpful



Personal Health Record Guidelines
Template for Emergencies
Personal Health Record – Write In Template
Personal Health Record – Electronic Template