Medical History Template

I've had numerous medical professionals comment on how much easier their job is when I hand them Aaron's medical history.  I've designed it so that the most important information is on the front page.  This would be anything needed to treat in an emergency, like current diagnosis, medications, weight, and so on.  Then it goes back in decreasing order of importance.  I put the template here in case anyone else finds it helpful.  It's been a work in progress, so feel free to adapt as you need to.  The best part about it is, all the important information is there, so I don't have to remember it when I'm already stressed.

Page 1 -- this is the most important page

Name                                                               MEDICAL ACTION (full code, dnr, no cpr, whatever)
Text Box: Insurance Company & policy #

EGA (gestational age @ birth wks/day
Birth weight (kg or g & lb/oz)
Blood type  (O+, O-, AB+ ect)

Current weight
Date last weighed:  kg & lb/oz

Other important issues:
Trach size, vent settings, g-tube size etc that would need to be known ASAP in an emergency

Medical Allergies
Immunization Status
In this text box put:
Insurance Co & policy #
Date of birth
EGA (gestational age @ birth)
Birth weight & blood type
Current weight & date last weighed
Medical Allergies
Immunization status

Other important issues:
Trach size, vent settings
g-tube size, etc that would
be needed ASAP in an

123 Main St
Anytown, ST 00000
Dad & Mom’s names
123-456-7890 hm
123-456-7890 cell

Current Diagnosis
(list in descending order of importance)
Trisomy 18
Cardiac issue
Pulmo issue
Chronic cuteness

Current Meds
(medication & strength)                                    amnt & freq                                   
Oxygen (yes, it’s a med)                                    continuous
Sildenafil 2.5 mg/ml                                           2.5 ml q 6 hr

Discontinued Meds
(same set-up as current meds but w/ dates and reason)
Septra                                                             3.0 ml bid m/d-m/d/yy UTI
Ciprofloxin 100mg/ml                                    .75 ml bid 
                                                                       1.5 ml bid 

Text Box: Feeding
Formula w/ calorie ct

Feeding schedule

Total:  (ml/24 hours)
Create text box w/ feeding info
formula, feeding sched, &
24 hr total.

Page 2 (and so forth as needed to cover the history)

Current Physicians & Providers
(primary care first, then down in order of importance)

Best Doctor, MD  pediatrician
357 S. Center St
Anytown, ST  00000
987-654-1230 fax

In-home nursing

MD  cardiologist

MD pumonologist

MD  urologist

MD  geneticist

Early Intervention
OT  phone
PT phone

wheelchair shop
phone – contact name

Home Health Equipment 
(include after hours emergency #)

Company name, phone 
Oxygen (what they provide)

Company name, phone
Trach/Vent, O2 monitor, feeding supplies (what they provide)

Name of pharmacy
Phone number
Fax number

(list most recent first)
Dates admitted
Procedures done, other pertinent info.  Try to keep it short.

Dx:                  Tracheitis pseudomonas, eye infx
Rx:                  Cirpo 5g/100ml 1.5 ml bid for 10 days

Dx:                  Psuedomonas pneumonia
Rx:                  Cipro 100mg/ml  0.75 ml bid,  Inc tidal volume 70, 1 ml air in cuffed trach
                  Synagis m/d/yy

G-tube, Nissen, Tympanostomy, Bronchosope m/d/yy
Tracheostomy m/d/yy
Ventilator settings
18 bpm
50 tidal volume
0.3 sec/I time
13 pressure support
Alarm 45 high, 5 low pressure
Sensitivity 2
Limited echo m/d normal cardiac function, PHT not measured
Discharge:  Inc Previcid from 1.0 ml to 1.33 ml daily.

Dx:                  Hypoxia
                  Pulmonary hypertension
NJ tube placement – 44 cm nose to hub.  24 kcal breastmilk/formula.  456 ml@22ml/hr over 24 hours

Mm/dd-mm/dd/yyyy (in this case, since it’s NICU, from date of birth to discharge)
Dx:                  Trisomy 18
Respiratory insufficiency
Mild pulmonary hypertension
Dysplastic tricuspid valve
Rx:                  Poly-vi-flor w/ iron .05 ml/daily
                  O2 ¼ l/min

Doctor’s Visits
(again list most recent first, record provider visits & telephone calls)

Date                 Dr. (full name)                 Notes(try to keep to 1-3 lines, very brief overview)

5/9/11               T/C cardio                Inc sildenafil to 2.5 ml q 6 hr based on new weight.
5/6/11               Dr. K                        Weight check – 5.9kg; inc feeds to 720 ml/day, prevcid to 2ml
5/4/11               T/C Dr K                  HUGE desat (33%), order labs/x-ray @ Riverton.  X-ray good, 
                                                                  most labs good, WBC 19,000.  Rx cipro1.5 bid for 10 days.
5/2/11               N H, AUD                 ABR test shows almost no hearing, but responds to aud stimuli    
                                                                  with movement and inc heart rate.  Refer to School for 
                                                                  Blind and Deaf for PIP EI.
3/29/11             Shriners                    Ortho consult. Splints for hands, 4-5 hr for thumb, sleeping for
                                                                   resting splints.  Spine okay.  Club foot clinic in June

3/25/11             Dr. K                         9 mo check up.  Looks great!  Last Hep B & Synergis shot
                                                                   24 ½ inch, 12# 1oz, head circ 40.9cm, labs in 1 month

3/9/11               Trach/vent clinic       Increase feeds.  Keep 1ml air in cuff.  Place trach when
inhaling.  Check ear tubes during lip repair & do ABR.  Lower brady setting to 60.  2nd flu shot.  Rx:  Tramcinolone acetnide bid prn for g-tube

Early Intervention or other Therapies
(use same format as dr visits)

4/1/11                 OT                             Use ball for stretching.  Lie down on lap for tummy time.
3/23/11               OT                             Work on standing muscles. Stretch hands.  Sitting. Reaching
 objects, swinging in a blanket.

2/8/11                 Hearing test               Referred both ears.  Need ABR
10/8/10               OT                              Use yoga ball for strength training.  Cellophane as
visual/auditory stimulation.  Keep stretching hands
8/27/10               self decision                Suspend use of bottle & oral feeds.  Much fussier, gagging,

vomiting after feeds, mult desats.  Wonder if, although he can protect his airways, if he gets “tired” & it’s too hard.  Will try again starting next Tuesday.
8/31/10               self decision                Discontinue bottle indefinitely after call to Dr. K.

Outpatient Studies                 
(studies/labs done on an outpatient basis – same format as dr visit)
7/30/2010           PCMC                        Echo
8/17/2010           PCMC-Riverton        Swallow study
9/8/2010             AFH                           Hearing screen DPOAE

*Use footer to date each time you update so you know how recent info is.
*Use abbreviations common to your area to save space – i.e. in Utah, everyone knows that PCMC is
Primary Children’s Medical Center and UVRMC is Utah Valley Regional Medical Center.
*Make changes you need to make this work for you.  It is not a Bible.  It is a work in progress.


  1. I wish all of my families with chronically ill patients would create a list like this. I would add allergies to page one though.

  2. Oops, it doesn't copy and paste real well onto blogger, so I was kind of recreating it as I went. On my sheets, the ones clipped to his meds chart, it says in bold, right below the vent setttings box: No Known Medical Allergies and Immunizations Current (because they always are). I agree. a MUST for any EMS trying to treat a patient.

  3. We keep something similar for Lily. However, because her allergies are extreme, we list them above her diagnoses. Versed, a very common in-the-field sedative, causes Lily to code, her heart and breathing to stop completely. None of the rest of her allergies are THAT bad, but I agree with you and the above commenter... we have to share those allergies to protect our kids.