Name: ____________________________________
Address: __________________________________
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Telephone: _________________________________
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Emergency Contact: __________________________
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Allergies: __________________________________
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Past Illnesses or Operations: ___________________
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Doctors' Names and Phone Number(s): ___________
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Medical Insurance Company and Number(s): _______
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Use this record to write down the date you receive the tests and the results. Try to remember to bring it with you each time you see a doctor.
This record will also help you keep track of when you need your next test or checkup.
| Checkup/Test | Date/Results | |||||
| Blood Pressure | ||||||
| Blood Sugar | ||||||
| Bone Density | ||||||
| Cholesterol | ||||||
| Dental Visits | ||||||
| Hearing | ||||||
| Tuberculosis | ||||||
| Vision | ||||||
| Weight | ||||||
| Type of Test/Exam | Date/Results | |||||
| Colorectal Cancer Test | ||||||
| Mammogram | ||||||
| Oral Cancer Exam | ||||||
| Pap Test | ||||||
| Prostate Cancer Test/Exam | ||||||
| Immunization (Shot) | How Often | Date(s) Received | |||||||
| Tetanus-Diphtheria | Every 10 years | ||||||||
| Flu | Every year after age 50 or sooner if at risk (Go to Text) |
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| Pneumonia | Once at age 65 or sooner if at risk (Go to Text) |
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| Hepatitis B | If at risk (Go to Text) |
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Write down the name of each medicine you take, the reason you take it, and when you start and stop in the spaces below. Add new medicines when you get them. You can show the list to your doctor and pharmacist. You may want to make copies of the blank form so you can use it again.
| Name of Medicine | Reason Taken | Date Started | Date Stopped |
|---|---|---|---|
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Pocket Guide to Staying Healthy at 50+