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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

Printable Transition Toolkits 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.

Printable Transition Toolkits Click here for a printable PDF version of this guide.

Updated 04/26/13 by necmp-staff
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