Personal
Information
Staying on top of your health
history can be challenging. The records in this
guide can help you keep
track of information. First, record your background
information here. You
can access other records for preventive
care, cancer
tests,
flu
shots, tetanus
shots, pneumonia
shots, and medicines.
Name:______________________________________________________________________
Address: ____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Telephone: __________________________________________________________________
Emergency Contact: ___________________________________________________________
___________________________________________________________________________
Allergies: ____________________________________________________________________
____________________________________________________________________________
_______________________________________________________
Doctor's Phone Number(s) : ___________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Medical Insurance Number(s): _________________________
_______________________________________________________
Personal Prevention Chart
Cancer
Test Chart
Flu
Shot Chart
Tetanus
Shot Chart
Pneumonia
Shot Chart
Medicine
Chart
Return
to Personal Prevention Charts
Return
to Staying Healthy at 50+
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