Printable Medical Record Form

Doctor Writing Medical Report

A printable medical record form can be a quick reference guide to your medical history in an emergency situation. Many people also keep a copy on hand as a reminder of vital information to fill out questionnaires at routine medical appointments. It's a helpful tool for remembering medical history, current medications, and more.

Printable Medical Record Form

Suggested Information

Click on the image above to download a printable medical record form. If you need help downloading the printable, check out these helpful tips.

When trying to decide what information to list on a medical record form, consider the information that would be important for a medical professional to know about you in the event of an emergency when you can't disclose medical history information. If you're incapacitated, what do the medical professionals trying to help you need to know?

  • Pre-existing conditions: If you have a medical condition that would affect the way you are treated in a medical emergency, you should make sure to include this information in a prominent place on the form. Examples of these types of conditions include diabetes, heart conditions or other chronic ailments that need to be known by any medical professional treating you in an emergency.
  • Allergies: There are some medications that might be used in an emergency that can be very dangerous for a person with an allergy to the medication. For your own protection, it is a good idea to list any medications that you have an allergy to or that you have experienced an adverse reaction from. This information will be invaluable to medical professionals treating you.
  • Contact information for your primary physician: Emergency medical personnel will want to consult with your primary physician when the opportunity arises. Be sure that the contact phone number you list on the form is current. You should also include contact information for an emergency contact, and if the form is for a minor you should include parent or guardian contact information.
  • Medications: Include a complete list of any medications you routinely take, including any over-the-counter medications and herbal supplements as these can have dangerous interactions with other drugs. You want to make sure that any emergency medications that are administered to you do not have contraindications with the medicines already in your system.

Routine Information

A medical record form isn't only for medical emergencies. Many people use these forms in an attempt to keep their own medical history straight and to make it easier to fill out medical forms when visiting a doctor. Recalling your family's medical history from memory every time you go to the doctor can be a challenge, especially if you're stressed, distracted or feeling unwell. Having the information written down somewhere makes it easy to fill out intake forms.

In addition to the information listed above, consider adding the following information to your form to make it easier to keep your medical history straight:

  • A chronological list of surgeries
  • A chronological list of major injuries or illnesses
  • A complete listing of immunizations
  • Information regarding pertinent family medical history
  • Dates of last physicals
  • Any pertinent medical information from other exams, including vision and dental

Women should additionally include information regarding any pregnancies or miscarriages, and if the form is updated regularly then information regarding the date of the woman's last menstrual cycle should be included.

Using the Form

Once the form is complete, be sure to carry a copy with you by tucking it in your purse or wallet. This will make it easier for emergency medical staff to reference in the event of an emergency.

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Printable Medical Record Form