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Personal Medical RecordsKeeping Track of Your Personal Medical Records
Personal Medical History Section 2 is intended for use by individuals with a chronic illness. As with Section 1, copy and paste Section 2 to a Word program. Then fill it out, print it and keep it in a secure place. Have it available when you are seeing a new doctor or where ever you want to apply or use your medical record information.
Personal Medical History Section 21 Defined Bleeding Disorders Do you have a known or defined bleeding disorder? Example: VonWillebrandt's Disease, Hemophilia A, Hemophilia B If Yes, specify: Details of the Bleeding disorder are: How is this disorder treated? List exact type of replacement therapy used, typical number of units administered, frequency, route of administration, i.e. IV, SubQ, etc. If you are on a home therapy program please also list the agency, usual nurse and contact numbers. None Cryoprecipitate DDAVP (Stimate) Factor IX Concentrate Factor VIII Concentrate Contact numbers: 2 Transfusion Information Details of Transfusion Information are: Have you ever been transfused with blood or blood products? If yes, specify: Circumstances: Units: Date: Have you ever had adverse reactions to blood or blood products? If yes, specify type of reaction: Back Pain, Dark Urine, Hives, Itching, Low blood Pressure, Rash 3 Blood Compatibility / Antibody Information Details of Transfusion Information are: If you were transfused, were there any difficulties finding compatible blood? Do you have any know Antibodies to blood products as a result of prior transfusion (Alloantibodies)? If Yes, specify the type of antibody if you can (example: anti-E, andtikell) Do you have any know Antibodies to your own red blood cells causing anemia or transfusion difficulties (antibodies not caused by prior blood transfusion)? If yes, specify the type of antibody if you can: Are you: (This is important for treating medical personnel to know for their protection) Hepatitis B+ Hepatitis C+ HIV+ 4 Dialysis/Kidney Failure Treatment Details of Dialysis/Kidney Failure Information are: Center Name and Phone Number: Center Fax Number: Dialysis Center Schedule: Dialysis Type: CAPD, CPPD, Hemodialysis, Plasmapheresis Spouse's Full Name: If Plasmapheresis, list frequency: Type of shunt or catheter in place for dialysis or plasmaphereisis and Anatomic Location (example: Tenckoff catheter; subclavian catheter, femoral catheter, neck, shoulder, arm, abdomen) Date placed or last revised: Location: Surgeon: Hospital: List your Dialysis Bath Formula (Dialysate Formula) if you can (this can be obtained off the solution bag label) 5 Cancer Treatment Are you on Chemotherapy, Hormone Treatment of Other Therapy for Cancer? If yes, provide the following information: Current Chemotherapy Regimen Chemotherapy Drug: Dosage: Frequency: Date of last treatment: Hormone Treatment (example: Tamozifen, Lupron, Arimidex, etc.) Drug: Dosage: Route of Administration: (example: subQ, by mouth, etc.) Frequency: Other Therapy (example: interferon, interieukin, etc.). Drug: Dosage: Route of Administration: Frequency: 6 Radiation Therapy Details of Radiation Therapy are: Are you now being treated with or have you ever received Radiation Therapy? If yes, provide the following information: Reason for Treatment: Anatomic location treated: (e.g. head and neck, spine, etc.) Number of Treatments: Dates: Radiation Center: 7 Bone Marrow Transplant Details of Bone Marrow Transplant are: Have you ever received a Bone Marrow Transplant or Peripheral Blood Stem Cell Transplant? If yes, provide the following information: Bone Marrow Transplant (BMT) Type: Autologous (yourself a donor) Bone marrow and stem cell graft Bone marrow graft only HLA matched sibling (brother or sister) donor (allogeneic) HLA matched unrelated donor (allogeneic) Identical twin donor (syngeneic) Peripheral Blood Stem Cell Transplant (PBSCT) Type: Autologous (yourself a donor) Bone marrow and stem cell graft Bone marrow graft only HLA matched sibling (brother or sister) donor (allogeneic) HLA matched unrelated donor (allogeneic) Identical twin donor (syngeneic) Transplant Center: 8 Bone Marrow Chronic Graft versus Host Disease Details of Bone Marrow Chronic Graft versus Host Disease are: Do you have any Chronic Graft versus Host Disease (cGVHD) as a result of your Bone Marrow or Stem Cell Transplant? If yes, provide the following information: Severeness: Mild Disease, Moderate Disease, Severe Disease What organs are affected? Liver, Mucus Membrane, Skin, or Other (If other, specify): What medications do you take to control your GVHD? (examples: Presdnisone, Methotrextate, ATG) Dosage: Any other BMT or PBSC Transplant related complications? 9 Solid Organ Transplant Have you had or are you being evaluated for Transplantation of a Solid Organ? If yes, provide the following information: Type of Transplant: Heart, Heart and Lung, Kidney (cadaver donor), Kidney (Living Donor), Liver, Lung, Pancreas or Other: Peripheral Blood Stem Cell Transplant (PBSCT) Type: Autologous (yourself a donor) Bone marrow and stem cell graft Bone marrow graft only HLA matched sibling (brother or sister) donor (allogeneic) HLA matched unrelated donor (allogeneic) Identical twin donor (syngeneic) No stem cell selection used Postive stem cell selection used Stem cell selection unknown Transplant Center: 10 Solid Organ Transplant Chronic Graft versus Host Disease Details of Solid Organ Transplant Chronic Graft versus Host Disease are: Do you have any Chronic Graft versus Host Disease (cGVHD) as a result of your Solid Organ Transplant? If yes, provide the following information: Severeness: Mild Disease, Moderate Disease, Severe Disease What organs are affected: Liver, Mucous Membrane, Skin or Other: What medications do you take to control your GVHD? (examples: Presdnisone, Methotrextate, ATG) Dosage: Any other Solid Organ Transplant related complications? (describe) Personal Medical Records - Section 2 Disclaimer Nothing contained in Answer My Health Question / Personal Medical Records is intended to be instruction, medical diagnosis or treatment oriented. It is not to be relied on to suggest a course of treatment for a particular individual, nor should it be used in place of a visit, call, consultation or the advice of your physician or other qualified health care provider. Answer My Health Question / Personal Medical Records will not be liable for any personal injury, damage and/or liability arising out of your use of the Personal Medical Records. Please use the Contact Us page for any questions or comments you may have regarding the Personal Medical Records page. Return to My Medical History from Personal Medical Records Tags: Personal Medical Records, answer my health question, personal medical record, medical records
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