Suggested Personal Medical Record Document


MEDICAL SUMMARY

Name:          
DOB:         Time:  
Hospital:

Birth Weight:           Length:         Apgars:
Birth:
Complications:
Maternal Blood Type:
Baby Blood Type (if known):

IMMUNIZATIONS

DPT                       
TdaP                                 
IPV                         
HIB               
Rotavirus        
Hepatitis B    
Hepatitis A                 
MMR                
Varivax            
Meningitis ACYW
Meninigitis B          
Gardasil HPV    
TB Test            
Influenza  
​COVID      

MEDICATIONS - (chronic daily use)             REASON                    START DATE           END DATE

ALLERGIES

ACUTE ILLNESS

DOCTOR VISITS


HOSPITALIZATIONS



VITAL SIGNS & GROWTH
Date            Age        Weight             Height             HC                  BP


BLOOD TESTS
Test Name            Value         Date


PHYSICIANS



ADDITIONAL NOTES