Free Medical Record Sheet

Patient Name

Jonatan Farrell

Date of Birth (MM/DD/YYYY)

07/15/2055

Gender

Male

Address

Cincinnati, OH 45201

Phone Number

222 555 7777

Emergency Contact Name

Jane Farrell

Emergency Contact Phone Number

222 555 7777

Relationship to Patient

Spouse

Primary Care Physician

Dr. [YOUR NAME], MD

Current Medications

Astrovent 20 mg, once daily
OmegaCaps 5,000 IU, every evening

Allergies

Penicillin
Shellfish

Chronic Conditions

Type 2 Diabetes
Hypertension

Surgical History

Appendectomy (2070)
Laser Cataract Surgery (2085)

Family Medical History

Father: Coronary Artery Disease
Mother: Type 2 Diabetes

Date of Visit

12/03/2090

Reason for Visit/Chief Complaint

Persistent fatigue and shortness of breath

Symptoms (Duration, Severity, etc.)

• Fatigue for 2 months, worsening in the last 2 weeks

• Mild shortness of breath during exertion

Vitals

Blood Pressure: 145/92 mmHg
Heart Rate: 88 bpm
Temperature: 98.6°F (37°C)
Weight: 190 lbs (86.18 kg)
Height: 5’10” (177.8 cm)

Diagnosis

Likely anemia, pending lab confirmation

Treatment Plan

• Order complete blood count (CBC) and iron studies

• Recommend dietary adjustments to increase iron intake

• Schedule follow-up in two weeks

Medications Prescribed

Iron Supplements 325 mg, once daily

Follow-Up Instructions

Monitor energy levels and report any worsening symptoms

Specialist Referrals

Hematologist