Example of a Personal Medical Record Document (Google Doc)
MEDICAL SUMMARY
Name: James Edward Murphy
DOB: 7/10/2010, Time 8:07 am
Hospital: Memorial Hospital, Denver, CO
Birth Weight: 7#9 Length: 20.5in Apgars: 9, 9
Birth: C-Section
Complications: mild jaundice
Maternal Blood Type: A+
Baby Blood Type (if known):
IMMUNIZATIONS
DPT 9/17/10 11/18/10
TdaP
IPV 9/17/10 11/18/10
HIB 9/17/10 11/18/10
Pneumo 9/17/10 11/18/10
Rotavirus 9/17/10 11/18/10
Hepatitis B 7/12/10
Hepatitis A 7/14/11
MMR 8/14/11
Varivax 8/14/11
Menactra
Meningitis B
Gardasil HPV
TB Test
Influenza
MEDS - (chronic daily use) REASON START DATE END DATE
Phenobarbital 50 mg once daily Seizures 7/10/13 8/10/14
Albuterol Inhaler - 2 puffs Asthma 9/12/15
ALLERGIES
Amoxicillin (penicillin) 9/18/13 - hives
ACUTE ILLNESS
1/5/11 Cold - no meds
10/8/12 Right Ear Infection - Dr Brown - Amoxicillin
2/25/13 Right Arm Fracture - Dr. Smith Ortho
7/10/13 Seizures - Dr Brown / Dr Jones - Phenobarbital
9/10/13 Strep Throat - Dr Brown - Amoxicillin
6/12/15 5 Stitches to Left Knee – Lurie ER
9/12/15 Asthma - Dr Brown - Albuterol Inhaler
DOCTOR VISITS
9/17/10 2 month Routine Visit, shots
11/18/10 4 month Routine Visit, shots
1/18/12 6 month Routine Visit, shots
11/2/12 15 month Routine Visit, shots, blood test for anemia (normal)
HOSPITALIZATIONS
1/14/15 Influenza - hosp at Lurie for 2 days
VITAL SIGNS & GROWTH
Date Age Weight Height HC BP
7/14/10 4d 7#10 oz 20.5 in 13.375in
8/11/10 1m 9#13 oz 23 in 14.25in 60/40
BLOOD TESTS
Test Name Value Date
Phenobarbital 15 9/10/13
PHYSICIANS
David Johnson, MD
Pediatrician Birth until 12 months
1234 Main Street; Denver, CO 65432 654/987-9876
Donald Brown, MD
Pediatrician 1 year > current
233 E Erie #304; Chicago, IL 60611 312/280-1480
Dr. Michael Smith
Orthopedics Broken Right Arm 2/25/13
1234 Center St; Chicago, IL 60678 312/543-5151
Dr. George Jones
Neurologist Seizures 7/10/13
1234 West Ave; Chicago, IL 60678 312/543-5252
Dr Susan West
Ophthalmology General Eye Care 8/10/14
1234 East Ave; Chicago, IL 60678 312/543-5353
ADDITIONAL NOTES
Seizures started at 3 years of age, normal EEG - meds stopped one year later, no recurrence
Name: James Edward Murphy
DOB: 7/10/2010, Time 8:07 am
Hospital: Memorial Hospital, Denver, CO
Birth Weight: 7#9 Length: 20.5in Apgars: 9, 9
Birth: C-Section
Complications: mild jaundice
Maternal Blood Type: A+
Baby Blood Type (if known):
IMMUNIZATIONS
DPT 9/17/10 11/18/10
TdaP
IPV 9/17/10 11/18/10
HIB 9/17/10 11/18/10
Pneumo 9/17/10 11/18/10
Rotavirus 9/17/10 11/18/10
Hepatitis B 7/12/10
Hepatitis A 7/14/11
MMR 8/14/11
Varivax 8/14/11
Menactra
Meningitis B
Gardasil HPV
TB Test
Influenza
MEDS - (chronic daily use) REASON START DATE END DATE
Phenobarbital 50 mg once daily Seizures 7/10/13 8/10/14
Albuterol Inhaler - 2 puffs Asthma 9/12/15
ALLERGIES
Amoxicillin (penicillin) 9/18/13 - hives
ACUTE ILLNESS
1/5/11 Cold - no meds
10/8/12 Right Ear Infection - Dr Brown - Amoxicillin
2/25/13 Right Arm Fracture - Dr. Smith Ortho
7/10/13 Seizures - Dr Brown / Dr Jones - Phenobarbital
9/10/13 Strep Throat - Dr Brown - Amoxicillin
6/12/15 5 Stitches to Left Knee – Lurie ER
9/12/15 Asthma - Dr Brown - Albuterol Inhaler
DOCTOR VISITS
9/17/10 2 month Routine Visit, shots
11/18/10 4 month Routine Visit, shots
1/18/12 6 month Routine Visit, shots
11/2/12 15 month Routine Visit, shots, blood test for anemia (normal)
HOSPITALIZATIONS
1/14/15 Influenza - hosp at Lurie for 2 days
VITAL SIGNS & GROWTH
Date Age Weight Height HC BP
7/14/10 4d 7#10 oz 20.5 in 13.375in
8/11/10 1m 9#13 oz 23 in 14.25in 60/40
BLOOD TESTS
Test Name Value Date
Phenobarbital 15 9/10/13
PHYSICIANS
David Johnson, MD
Pediatrician Birth until 12 months
1234 Main Street; Denver, CO 65432 654/987-9876
Donald Brown, MD
Pediatrician 1 year > current
233 E Erie #304; Chicago, IL 60611 312/280-1480
Dr. Michael Smith
Orthopedics Broken Right Arm 2/25/13
1234 Center St; Chicago, IL 60678 312/543-5151
Dr. George Jones
Neurologist Seizures 7/10/13
1234 West Ave; Chicago, IL 60678 312/543-5252
Dr Susan West
Ophthalmology General Eye Care 8/10/14
1234 East Ave; Chicago, IL 60678 312/543-5353
ADDITIONAL NOTES
Seizures started at 3 years of age, normal EEG - meds stopped one year later, no recurrence