A Personal Health Record (PHR) has information that can be helpful for you whenever you see a doctor or nurse. Your PHR is private. This information is stored no where else.
You can print your PHR now. We also recommend you keep your personal health record on your computer or on a "flash drive" (or even a cell phone) so that a doctor or nurse can use the information or import it as TEXT into an electronic health record. You may change your PHR at any time by being connected to the Internet and choosing EDIT PHR or repeating www.howsyourhealth.org.
| First Name | Patrick |
| Last Name | Livinski |
| Address 1 | 1 Court Street |
| Address 2 | |
| City | Lebanon |
| State | New Hampshire |
| Zip | 03766 |
| Phone | 603-653-2345 |
| Fax | |
| Email Address | info@venix.com |
| Date of Birth (mm/dd/yyyy) | 1948-10-26 |
| Penicillin |
| Blood Pressure medications (such as Propranolol, Metoprolol, Enalapril, Norvac, Vasotec, Prinivil, Zestril) Breathing medications (such as Albuterol inhaler, Theophylline) Pain medications (such as Ibuprofen, Motrin, Aspirin, Percocet, Darvocet) |
|
| Write medications not listed: | Allopurinol |
| Who would decide for you? | Family members |
| Who is this person? | Uncle George |
| Do they know what you would want? | Yes |
| Is what you want in Writing? | Yes |
| Name | Mary Livinski |
| How to contact | Phone 222-333-4567 |
| My primary doctor | Gordon Moore |
| Additional doctors | Cardio Bob |
| Person who helps at home | No needed |
| Most recently in hospital for | Knee Replacement |
| The Change I want to make is: (be very specific, what when, how?) | Increase exercise to strengthen knee and keep weight in line. |
| My Goal for the next month is: | Lose 5 pounds and increase knee strength to 15x15 |
| The Steps I will take to reach the Goal: | Go to Y every other day and walk with Joe every day at noon. |
| The things that will make it hard to reach the Goal: | Bad weather, laziness. |
| The ways I can overcome those things that may get in the way: | Joe and I have $100 from each other that can be drawn down by $10 for every "miss" |
| My confidence that I can reach my goal. (0 is not confident at all; 10 is very confident) |
9 |
| The help I will probably need: | Not yet |
| Doctor wants my medicines actually listed as they appear on bottles: metoprolol 50 BID; ibuprofen 200 tid and salmeterol inhaler. |
| Doing Daily Activities | Some difficulty |
| Bothered by Emotions or Feelings | Not at all |
| Have you had limitations on Social Activities | Slightly |
| Do you have much pain? | Mild pain |
| In the PAST 3 MONTHS did you have an illness or injury that kept you in bed for all or most of the day? | Yes |
| Headache | Never |
| Stomach or abdominal pains | Never |
| Dizzy spells, tiredness or fatigue | Never |
| Chest pains | Never |
| Eating or weight problems | Sometimes |
| Skin problems | Never |
| Trouble urinating | Never |
| Sexual problems | Never |
| Asthma or breathing problems | Often |
| Joint pains | Sometimes |
| Backaches | Seldom |
| Trouble sleeping | Never |
| Foot trouble | Seldom |
| How confident are you that you can control and manage most of your health problems? | Very confident |
| Are you a smoker? | No |
| How often do you practice good Health Habits | Most of the time |
| How often have you been told to reduce drinking | Never |
| A test for fat (cholesterol) in the blood within the past two years? | Yes |
| A test for cancer of the bowel within the past two years? | Yes |
| Good education about the advantages and disadvantages of a blood test for prostate cancer within the past two years? | Yes |
| Cancer |
| Any other family disease |
| Do you have Social Support to help | Yes, as much as I wanted |
| Trouble in relationships | None of the time |
| Do you have enough money to buy the things that you need to live everyday such as food, clothing, or housing? | Yes, always |
| High blood pressure | |
| Arthritis | |
| Asthma, bronchitis or emphysema | |
| In the past year have you been in the hospital or visited an emergency room because of any of these problems? | Yes |
| In the PAST YEAR did you stay in a hospital overnight or longer? | Yes |
| Other Conditions | for knee surgery only |
| Stomach or Bowel: | Not concern: blood in stools, sick to stomach, vomiting, abdominal pain, constipation, diarrhea |
| Heart: | Not concern: chest pain, heart 'pounding or skipping' |
| Eyes: | Not concern: double vision, sudden loss of vision |
| Lungs: | Concerns: wheezing Not concern: cough, shortness of breath |
| Sexual: | Not concern: impotence, irregular period, vaginal bleeding after menopause |
| Urine: | Not concern: frequent or painful urination, bloody urine |
| Feelings: | Not concern: depression, anxiety, suicidal thoughts |
| Bones or Muscles: | Concerns: joint pain Not concern: muscle weakness |
| Skin: | Not concern: new lumps or masses, rash, changing mole, breast mass |
| General: | Not concern: excessive thirst, fever, weight loss, extreme fatigue, bruising and bleeding |
| Nervous system: | Not concern: headache, persisten weakness or numbness on one side of the body, falling |
| Ear, Nose, Mouth, or Throat: | Not concern: sore throat, runny nose, ear pain |