Health Record
[YOUR COMPANY NAME] | [YOUR COMPANY ADDRESS]
I. Patient Information
Full Name: Duane Wiza
Date of Birth: 03/15/2059
Gender: Male
Address: Buffalo, NY 14201
Phone Number: 222 555 7777
Email Address: duane@you.mail
Emergency Contact:
II. Health Insurance Information
Insurance Provider: NovaCare Health Solutions
Policy Number: NC-2089-00012345
Group Number: 67890
Coverage Details: Comprehensive Plan (includes routine, specialist, and emergency care)
III. Medical History
Medications:
Name: Metformin
Dosage: 500 mg
Frequency: Twice Daily
Name: Lisinopril
Dosage: 10 mg
Frequency: Once Daily
IV. Immunization Records
V. Vital Signs (Most Recent)
Date of Measurement: 11/25/2089
Height: 6 ft 1 in (185 cm)
Weight: 200 lbs (90.7 kg)
Blood Pressure: 130/85 mmHg
Pulse Rate: 72 bpm
Temperature: 98.6°F (37°C)
VI. Clinical Notes
Primary Physician: Dr. [YOUR NAME]
Date of Last Visit: 11/25/2089
Summary of Findings: Patient presents stable vital signs with well-controlled diabetes and hypertension. Advised to maintain current medication regimen and increase physical activity.
VII. Laboratory/Diagnostic Tests
VIII. Treatment Plan
IX. Patient Acknowledgment
I, Duane Wiza, confirm that the above information is accurate to the best of my knowledge.
Signature: _________________________
Date: 12/03/2089
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