My Own Medical Info

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0ParListParKey ForListForKey Default MoreOpts
Doc Name Med Prescriber--Unknown--OTC (Drug),OTC (Vitamin),OTC (Herbal)
Phar Name Med Provider --Unknown--(doctor),(not applicable)
Doc Name Hist Doctor --Unknown--None
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Personal Data Your own ID and contact information

0HeadText ElemMaxCellType PrintCust1 Cust2 Title
Name 30 celltextin p Use the format that matches your doctors' medical records
Birth Date 20 celltextin p Use mm/dd/yyyy format to save space
SS# 11 celltextin p Social Security Number
Blood 3 celltextin p Blood Type (O, A, B, AB) and RH factor ( + or - )
Home Phone 20 celltextin p
Cell Phone 20 celltextin p
Work Phone 20 celltextin p
Address 35 celltextin p Your primary residence
Town 25 celltextin p
State 15 celltextin p Use the 2-letter postal abbreviation to save space
Zip 10 celltextin p
Printable 1 cellflag PickPrint Uncheck this to hide the row when printing
Color 10 cellflag PickColor Use colors to mark rows that have something in common
012345678910111213
Kent Allard7/31/1930835-03-1234AB-212-286-2860718-981-1234515-243-327379 7th Ave.New YorkNY10011pWhite

Medications Your (current) prescribed, recommended, and self-selected medicine

0HeadText ElemMaxCellType PrintCust1 Cust2 Title
Primary Name 30 celltextin p DrugLook The name actually found on the box or bottle
Alt Name 30 celltextin p DrugLook Familiar generic or brand name equivalent OR compound components
Purpose 35 celltextin p The ailment or condition treated by this medecine
Dose 15 celltextin p GetMedDose Usually specified in milligrams (mg) for pills or milliliters (ml) for liquids
Freq 15 celltextin p GetMedFreq How often it's taken: 1 Weekly? 3 Daily? As needed?
Prescriber 30 celloptin p GetPrescrib1 GetPrescrib2 The doctor (from your list) who prescribed or recommended the medicine
Provider 30 celloptin p GetProvider1 GetProvider2 The pharmacy (from your list) where you last purchased the medicine
Printable 1 cellflag PickPrint Uncheck this to hide the row when printing
Color 10 cellflag PickColor Use colors to mark rows that have something in common
0123456789
simvastatin(Zocor)elevated cholesterol20mgDailyJohn McIntyreCVSpRed
Plavixclopidogrelcoronary artery disease75 mgDailyJohn McIntyreWalgreenspRed
metformin-SR(Glucophage XR)non-alcoholic fatty liver disease 850 mgDailyRupert SayreCVSpBlue
Advair Diskusfluticasone propionateCOPD100 mcg2 DailyRupert SayreWalgreenspBlue
Advair DiskussalmeterolCOPD50 mcg2 DailyRupert SayreWalgreenspBlue
omeprazole(Prilosec)ulcers20 mg2 DailyRupert SayreCVSpBlue
amoxicillinulcers1000 mg2 DailyRupert SayreCVSpBlue
Biaxinclarithromycinulcers500 mg2 DailyRupert SayreWalgreenspBlue
sertraline(Zoloft)obsessive compulsive disorder50 mgDailyFrasier CraneCVSpOrange
Thiotimolinerosacea karlsbadensiscausal disassociation42 mcg As NeededSam Beckett--Unknown--pViolet
Radithorradiumchronic fatigue1 vialDailyNick Riviera(doctor)pGreen
Anguis Oleumpanaceaeverything1 bottleAt NightNick Riviera(doctor)pGreen
ketoconazole(Nizoral)athlete's foot2% creamDailyOTC (Drug)(not applicable)pWhite

Doctors Doctors you currently see - plus others that prescribed current medication or performed major surgery

0HeadText ElemMaxCellType PrintCust1 Cust2 Title
Name 30 celltextin p DocLookButt Just enter the Doctor's first and last name (leave off the "Dr.")
Specialty 25 celltextin p GetDocSpec General Practitioner, Cardiologist, Dermatologist, etc.
Phone 20 celltextin p Primary office phone number
Address 35 celltextin p DocMapButt Primary office address
Town 25 celltextin p Primary office town
State 15 celltextin p GetStateName Primary office state
Zip 10 celltextin p Primary office zip code
Other Info 30 celltextin p Other information such as a practice name
Printable 1 cellflag PickPrint To hide the row when printing, uncheck this box
Color 10 cellflag PickColor You may use colors to mark rows that have something in common
012345678910
John McIntyreCardiology310-369-100010201 W. Pico Blvd. Bldg 88, Rm 30Los AngelesCA90035pRed
Rupert SayreGeneral Practice515-243-32734 Times SquareNew YorkNY10036pBlue
Frasier CranePsychiatry212-975-432151 W. 52nd St.New YorkNY10019pOrange
Sam BeckettHistoric Anomalies818-777-1000100 Universal City PlazaUniversal CityCA91608pViolet
Nick RivieraQuack600-362-8672123 Fake St.SpringfieldNT12345pGreen
Peter VenkmanParapsychology310-244-4000 10202 West Washington Blvd. Culver CityCA90232pWhite
Stephen StrangeNeurosurgery212-576-4000135 W. 50th Street, 7th Floor New YorkNY10020pWhite
Heathcliff HuxtableDentistry818-464-960016027 Ventura Blvd.EncinoCA91436pWhite
Alan HarperChiropractor818-954-60004000 Warner Blvd.BurbankCA91522pWhite

Emergency Contacts People (in order of preference) who should be contacted in case of emergency

0HeadText ElemMaxCellType PrintCust1 Cust2 Title
Name 30 celltextin p The contact's full name
Relation 25 celltextin p GetRelation Indicate whether they are a spouse, son, daughter, friend, etc.
Home Phone 20 celltextin p Home phone number
Work Phone 20 celltextin p Work phone number
Cell Phone 20 celltextin p Cell phone number
Other Info 25 celltextin p more details about how or why to contact them
Printable 1 cellflag PickPrint To hide the row when printing, uncheck this box
Color 10 cellflag PickColor You may use colors to mark rows that have something in common
012345678
Margo LaneFriend415-955-8269323-965-7316pWhite
Harry VincentFriend312-649-3523248-458-7991call work # firstpWhite

Pharmacies Pharmacies where you regularly get prescriptions filled

0HeadText ElemMaxCellType PrintCust1 Cust2 Title
Name 30 celltextin p GetPharm Business name of the pharmacy (like CVS, Rite Aid, Walgreens, etc.)
Address 35 celltextin p The location you use most
Town 25 celltextin p
State 15 celltextin p GetStateName
Zip 10 celltextin p
Phone 20 celltextin p PharmPhoneButt (for calling in a prescription)
Fax 20 celltextin p (alternate method for sending prescriptions)
Other Info 30 celltextin p
Printable 1 cellflag PickPrint To hide the row when printing, uncheck this box
Color 10 cellflag PickColor You may use colors to mark rows that have something in common
012345678910
Walgreens200 Wilmot Rd.DeerfieldIL60015847 940-2500for brand namespWhite
CVS1 CVS Drive WoonsocketRI02895800-746-7287for genericspWhite

Medical History & Conditions Anything medically relevant that could affect diagnosis and/or treatment of a new problem

0HeadText ElemMaxCellType PrintCust1 Cust2 Title
Type 25 celltextin p GetIssueTypeThe general type of condition or event
Common Label 30 celltextin p Names of conditions like "diabedes" or "latex allergy" - also procedure names like "rhinoplasty" or "lasik"
Date 25 celltextin p Leave blank for current conditions
Details 50 celltextin p Specific relevant details
Doctor 30 celloptin p GetTreater1 GetTreater2 Doctor (from your list) who performed procedure or is currently treating a condition
Printable 1 cellflag PickPrint To hide the row when printing, uncheck this box
Color 10 cellflag PickColor You may use colors to mark rows that have something in common
01234567
Curable IllnessPeptic Ulcersn/abeing treatedRupert SayrepBlue
Disease-ChronicCOPDn/abeing treatedRupert SayrepBlue
Disease-Chronicliver diseasen/abeing treatedRupert SayrepBlue
SurgeryAtherosclerosis 3/17/2004Angioplasty for blocked LCXJohn McIntyrepRed
ImplantCoronary Artery Stent3/17/2004Endeavour (Medtronic) in LCXJohn McIntyrepRed
ImplantCoronary Artery Stent5/21/2005Xience V (Abbot) in LCXJohn McIntyrepRed
Chronic DiseaseFatiguen/abeing treatedNick RivierapGreen
Family HistoryLycanthropyn/a(maternal grandfather) monitored by >>Peter VenkmanpWhite
TransplantBibliographic Extension1/1/1988ultimately returned to donor Stephen StrangepWhite
Allergy-EnviromentPhotodermatitisn/a(generally avoid light to avoid symptoms)NonepWhite

Insurance Plans Insurance information that hospitals and doctors like to have before treating you

0HeadText ElemMaxCellType PrintCust1 Cust2 Title
Type 20 celltextin p GetInsType The type of Insurance (Medical, Prescription, Dental, Vision, etc.)
Company 30 celltextin p GetInsCo Company Name (like Medicare, Aetna, United Health etc.)
Plan 30 celltextin p The plan's name or title
Group ID 25 celltextin p The Group number - typically the same for co-workers using the same plan
Personal ID 25 celltextin p The ID number assigned to the specific insurance customer
Cust Phone 20 celltextin p The phone number provided for customers to call for assistance
Doc Phone 20 celltextin p The phone number provided for doctors and hospitals to call about billing issues
Fax 20 celltextin p A fax number that can be used to submit insurance claims
Other Info 30 celltextin p Important details not covered by the other categories
Printable 1 cellflag PickPrint To hide the row when printing, uncheck this box
Color 10 cellflag PickColor You may use colors to mark rows that have something in common
01234567891011
HealthMedicareParts A & B835-03-1234A800-633-4227pWhite
HealthMutual of OmahaMedigap Plan "C"793053MC835-03-1234 01800-228-7104800-775-1000pWhite
PrescriptionHumanaPreferred Rx PDPD43751234A6789866-945-4481800-448-6262Medicare Part DpWhite
DentalDelta DentalDeltaCare Individual27566314253-6475800-932-0783pWhite

Immunization All vaccinations - parts of combined vaccines like DPT and MMR should be entered separately

0HeadText ElemMaxCellType Print Cust1 Cust2 Title
Vaccine 30 celltextin p GetImmune The vaccine name based on the disease it helps you avoid
Doses Needed 2 celltextin p The date for the latest dose in a series OR your latest booster shot
Last Dose # 2 celltextin p If a vaccine is given as multiple doses, how many were administered so far?
Dose Date 20 celltextin p The date for the latest dose in a series OR your latest booster shot
Other Details 50 celltextin p More specific vaccine information, such as Brand name
Printable 1 cellflag PickPrint To hide the row when printing, uncheck this box
Color 10 cellflag PickColor You may use colors to mark rows that have something in common
01234567
Tetanus116/8/2009pWhite
Shingles113/24/2007ZostavaxpWhite
Influenza119/23/2013AFLURIApWhite
Hepatitis B329/16/2013Engenrix-B (1 more needed)pWhite
Personal Data
NameBirth DateSS#BloodHome PhoneCell PhoneWork PhoneAddressTownStateZip
Doctors
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Emergency Contacts
NameRelationHome PhoneWork PhoneCell PhoneOther Info
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Medications
Primary NameAlt NamePurposeDoseFreqPrescriberProvider
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Pharmacies
NameAddressTownStateZipPhoneFaxOther Info
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Medical History & Conditions
TypeCommon LabelDateDetailsDoctor
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Immunization
VaccineDoses NeededLast Dose #Dose DateOther Details
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Insurance Plans
TypeCompanyPlanGroup IDPersonal IDCust PhoneDoc PhoneFaxOther Info
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