Free Simple Patient Health Record (PHR)

Patient Information
Full Name: Allene Tillman
Date of Birth: 05/15/2050
Gender: Female
Contact Information:
Phone Number: 222 555 7777
Email Address: allene@you.mail
Address: Long Beach, CA 90801
Emergency Contact Information
Full Name: John Tillman
Relationship to Patient: Spouse
Phone Number: 222 555 7777
Medical History
Chronic Conditions: Hypertension, Type 2 Diabetes
Allergies: Penicillin
Past Surgeries:
Appendectomy, 07/12/2075 (No complications)
Medications:
Lisinopril 10 mg, once daily
Metformin 500 mg, twice daily
Immunization Record
Vaccination Name: Influenza Vaccine
Date Administered: 09/01/2090
Additional Notes: Annual vaccine up-to-date
Vaccination Name: COVID-19 Booster
Date Administered: 08/15/2090
Additional Notes: No side effects reported
Recent Medical Visits
Date of Visit: 10/25/2091
Provider Name: Dr. Emily Smith / Springfield Medical Center
Reason for Visit: Routine check-up
Outcome/Follow-Up: Blood pressure within target range; continue current medications
Additional Notes
Date Added: 11/15/2091
Details: Patient reports improved energy levels after starting yoga classes twice weekly
Prepared by: [YOUR NAME]
Date: 12/03/2061
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This Simple Patient Health Record (PHR) Template from Template.net offers a user-friendly and customizable solution for managing personal health records. Editable in our AI Editor Tool, this template is designed for individuals or healthcare providers to record vital medical details clearly and professionally, ensuring accuracy and accessibility in healthcare documentation.