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Sample Health History

This document contains health information for a patient named FIRSTNAME LASTNAME, including their address, emergency contact information, medical providers, insurance information, important health details, medications, and medical history. The patient's medical history includes a 2005 breast cancer biopsy and bilateral mastectomy, a 2006 brain tumor biopsy and emergent craniotomy for resection, and radiation and chemotherapy treatment from 2007-2008.

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Michael Buccowich
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102 views3 pages

Sample Health History

This document contains health information for a patient named FIRSTNAME LASTNAME, including their address, emergency contact information, medical providers, insurance information, important health details, medications, and medical history. The patient's medical history includes a 2005 breast cancer biopsy and bilateral mastectomy, a 2006 brain tumor biopsy and emergent craniotomy for resection, and radiation and chemotherapy treatment from 2007-2008.

Uploaded by

Michael Buccowich
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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HEALTH INFORMATION

FIRSTNAME LASTNAME Date: 12/8/2021


Blood Type:
Address Gender:
DOB:
Religion: UCLA Patient ID# 12345678

Spouse / Emergency: Phone: Children: DOB: Phone:


Spouse Lastname (562) 555-1212 Mobile Son 01/01/1990 (562) 555-1212
(562) 555-1212 x101 Work Daughter 01/01/1993 (562) 555-1212
Son 01/01/1996 (562) 555-1212
Parents: Phone:
Parents Lastname (562) 555-1212

Neuro-Oncologist: Primary Care: Infectious Disease: Neurosurgeon:


Doctor Lastname MD Doctor Lastname MD Doctor Lastname MD Doctor Lastname MD

Address Address Address Address


City ST Zip City ST Zip City ST Zip City ST Zip

(562) 555-1212 Office (562) 555-1212 Office (562) 555-1212 Office (562) 555-1212 Office
(562) 555-1212 Fax (562) 555-1212 Fax (562) 555-1212 Fax
Call first:
(562) 555-1212 Pager #12345
[email protected] [email protected] [email protected]

Health Insurance:
Primary: Medicare Pharmacy:
Secondary: HealthCare Ins Co Health Plan (12345) 123-123456-12 Good Neighborhood Pharmacy
Member ID 1234567
PO Box 1234 PO Box 1234
Group No 123456
City ST Zip City ST Zip
Payer ID 12345
(562) 555-1212 Member Claims (562) 555-1212 Office
(562) 555-1212 Providers Prescription Plan (562) 555-1212 Fax
(562) 555-1212 Pharmacists Rx Bin 12345
Copay: Rx Group XYZ Rx: FirstName
Office Spec ER Urg Rx PCN 9999 Tech: FirstName
$ $ $ $

IMPORTANT
No BP or blood draws on right arm – use left arm only. Right visual field cut and right side weakness due to stroke
Patient is a HARD STICK. She has a port catheter located
Compromised memory and cognitive function, aphasia
under her right clavicle.

MEDICATIONS
Meds list on separate sheet No known drug allergies
HEALTHCARE HISTORY
Date Event Detail Physician/Facility Inpatient
4/2005 Biopsy Breast cancer Lastname N
7/2006 Surgery Bilateral mastectomy, also removed right sentinel lymph node Lastname @ ZZZ Hospital Y
6/2006 Biopsy Primary brain tumor (Oligodendroglioma) Lastname @ ZZZ Hospital Y + ER
7/2006 Surgery Craniotomy: emergent brain tumor resection Lastname @ ZZZ Hospital Y + ER
9/2007 Radiation Daily radiation (six weeks) Lastname @ ZZZ Hospital N
9/2007 Chemo Temodar (Sep 2007 – Apr 2008) Lastname N

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