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Medical Health Summary

Use this form to save important health information

Two ways you can use this form are:

1. Download it as a Word doc directly onto your USB flash drive, open it with Microsoft Word, fill it out, and save it to your flash drive

2. Fill out the form online (below), then print it and store the paper version in a safe place

PDF Click here for a printable PDF version of this guide.

 

Date updated
Last Name
 First Name
Birthday
 Gender
 Weight
 Height
Address
City
 State
 Zip Code
Insurance Name
Insurance ID & Group #
Insurance Address & Phone Number
Metabolic or Genetic Condition
Medications/Supplements and Dosages
Allergies to Food, Drugs and Other Substances
Emergency Contact Name & Relationship
 Emergency Contact Phone Number
Pharmacy Name
 Pharmacy Phone Number
Immunizations: Type Date

Other medical information:

 

 

When you’re done filling out this Medical Health Summary, print it.

A final step toward completing your medical transition is meeting with your health care providers to discuss and fill out your Transition Plan.

PDF Click here for a printable PDF version of this guide.

Updated 08/02/10 by necmp-staff
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