Jump to content

Patient Guide - Information sheets


Information sheets to help you prepare for your trip to the ER or to a new medical practice.

The pdfs of these sheets can be downloaded here Patient Guide - medical trips.pdf for easy printing.

Medications - current

Name                    dosage              prescribed by                     to treat what symptom








NOTES:  allergies and notes about reactions to meds should be detailed here.

Medical History:

Illnesses:  (be sure to include when you had the illness, treatment for the illness and whether you completely recovered or are still being treated for this illness)


Surgeries:  (date, what the surgery treated, was it successful or not? If not, what lasting complications, if any)

Specific test ranges or numbers - standard to you.  
HR range:

BP range:


Doctor or medical professional most familiar with your illness


Email Address______________________________________


Edited by edriscoll

User Feedback

Recommended Comments

There are no comments to display.

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Add a comment...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

  • Create New...