Personal Health Information Packet
This packet is for your personal use. This can either
be used as a template to the MyHealtheVet
program – or as a standalone document. The
information that you put in the packet is up to you.
It is only a tool to help you keep track of your
healthcare as well as for those involved with your
healthcare.
Page 1
Personal Health Information
Allergies:
Allergy:
Reaction:
Date of Last
Reaction:
Treatment:
Emergency Contact Information:
In case of Emergency Notify:
Name/Relationship:
Contact Information:
Name/Relationship:
Contact Information:
Page 2
Insurance Information:
Insurance Provider:
Identification Number:
Insurance Provider:
Identification Number:
Customer Service
Number:
Advance Directives:
Living Will
Yes
No
Location
Power of Attorney: Health Yes
No
Who?
Power of Attorney:
Finances
No
Who?
Yes
Healthcare Providers / Physicians Involved with
Care: (VA Patient Response Center XXX-XXX-XXXX)
Health care Provider / Physicians
Name
Phone Number
Page 3
Your Medical Diagnoses/Conditions/Past Surgeries:
Medical History (Check all the appropriate boxes)
Date of Onset
Date of Onset
AIDS or HIV +
Osteoporosis
Sexually
Arthritis
Transmitted Disease
Tuberculosis
Joint Problems
Bronchitis
Kidney Disease
Shortness of
Limb
Breath
amputation
Emphysema/
Mental deficit/
COPD
dementia
Asthma
Frequent or
Severe Headaches
Diabetes
Traumatic Brain
Injury
Hypoglycemia
Epilepsy
Thyroid Problems
Stroke
Eye Problems
Seizures
/Glaucoma
Hearing
Dizziness
Impairment
Mental Health
Parkinson's
issues/PTSD
Stomach, Liver or
Spinal Cord
Intestinal Problems
Injury: Level
Heart Condition
Urinary or
Bowel deficits
Angina
Multiple
Sclerosis: Date of
onset
High Blood
Cancer
Pressure
Low Blood
Tumor
Pressure
Other
Other
Page 4
Past Surgeries (list major surgeries)
Type of Surgery
Date of Surgery
Current Medications:
VA Pharmacy Phone number: XXX-XXX-XXXX for prescription refills
Medication Name
Dose
Reason for Taking
Page 5
Current Living Situation:
Alone
Live with Family or Assisted Living
Friend
Nursing Home
Functional Status: Please Check the Amount of
Assistance you need for each activity in the correct box
Function
Bathing
Grooming
Dressing Upper
Body
Dressing Lower
Body
Toileting
Bladder
Management
Bowel
Management
Transfers
Comprehension
Speech
Problem Solving
Memory
Walking in the
house
Walking outside
the house
No Help Required
Need Some Help
Cannot help at all
Page 6
Swallowing:
Yes
No
Have a History (please give date)
Difficulty Swallowing
Food
Difficulty Swallowing
Liquids
Currently diagnosed with
dysphagia (Swallowing
difficulty)
Vision and Hearing:
For equipment provided by VA Hospital
please contact Prosthetics: PHONE NUMBER XXX-XXX-XXXX
Yes
(please give information on devices used)
No
Vision Problems
Blindness?
Glasses?
Contacts?
Hearing Problems
Hearing-aids?
Cochlear Implant?
Personal Risk Factors:
Alcohol Use
Yes
No
Smoking
Yes
No
Exercise
Yes
No
Drinks per Week
Number of Years
Packs per Day
Number of Years
Types of Exercise
Number of Days per Week
Page 7
Special Type of Diet
Restrictions
Other:
Immunization Status:
Immunization for Yes
Influenza
(Yearly)
Pneumonia
(Every 5 years)
Hepatitis B
(3 shot series)
Tetanus
(5 to 10 years)
Meningitis
(Only Once)
Gardacel
(3 shot series)
Shingles
(age 65 or older)
Other
No
Last Given
Remarks
Page 8
Prosthetic and Orthotics Information:
For equipment provided by VA Hospital please contact Prosthetics:
PHONE NUMBER XXX-XXX-XXXX
PROSTHESIS? Yes
Date obtained
No
Doctor
Provider or Prosthesis
Suspension
Contact Information for Prosthetic
Provider
Socks/Liners
Knee
Foot
Dates of Prosthetic Service:
ORTHOTIC DEVICE? Yes
Date obtained
No
Doctor
What is this orthotic used for?
Provider of Orthotic
Contact Information for Orthotic
Provider
Dates if Orthotic Service:
Do you use a wheelchair? Yes
Date obtained
Provider of Wheelchair
Wheelchair Vendor
Make/Model
No
Contact Information of Wheelchair
Provider
Contact Information for Vendor
Serial Number
Cushion Type
Dates if Wheelchair Service:
Page 9
Hospital of Choice:
Name of
Hospital
Phone Number
Addresses
Information
Page 10