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Personal Health Care Journal

Use this journal to take an active role in your own health care!

Journal Dates:
From: ________________     To: ________________

Directions for Using Your Personal Journal...

  • Ask yourself these questions before your appointment.
    • Is this appointment going to be covered by Medicare or my other insurance?
    • What are my symptoms, when did they start, what makes them better or worse?
    • What medication am I taking?
  • Take this journal to all your appointments.
  • Write down the answers to these questions as well as the results of the appointment in this journal.
    • Make sure that you understand what your physician is telling you before leaving your appointment. If you don't, ask him or her to explain the information in a different way.
  • Use this journal when checking your Medicare and health care paperwork for accuracy.
  • Take this journal with you when you travel, in case of emergency.

For Emergency Health Care Call: 911

My Medicare Part B Insurance Company (Carrier) is:

    Name ___________________________________   Phone ______________________________

My Medicare Part A Insurance Company (Fiscal Intermediary) is:

    Name ___________________________________   Phone ______________________________

My Medicare Supplemental Insurance Company is:

    Name ___________________________________   Phone ______________________________

Other Important Numbers:

_________________________________________________________________________________

_________________________________________________________________________________

Reminder: Do not write your Medicare number in this journal so that it may remain confidential.








List of Appointments

DateClinicPhysician and PhoneReason
    
    
    
    
    
    
    
    
    
    
    
    

List of Health Problems/Conditions

 
 
 
 

List of Allergies

DateAllergic to what?Symptom/Reaction
   
   
   
   
   





List of Operations/Surgeries

DateType of OperationHospital/Clinic
   
   
   
   
   
   
   
   
   
   
   
   

List of Medical Equipment and Supplies

DateEquipmentProvider of EquipmentPhysician
    
    
    
    
    
    
    
    
    
    
    
    



Medications

Drug Name
(common name)		Color/
Shape		When
Started		PurposeStrength/
Dosage		Directions
      
      
      
      
      
      
      
      
      
      
      




























Physician Visit: Record #1

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #2

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #3

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #4

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #5

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #6

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #7

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #8

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #9

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #10

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #11

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







Physician Visit: Record #12

Date: ________________

Physician/Care Provider: ___________________________________

Questions/Symptoms/Problems
 
 
 
 
*list by importance, when it started, and what makes it better or worse

Care Plan/Special Instructions/Prescriptions
 
 
 
 
 
 

Personal Health Data

Weight: ___________________________________

Blood Pressure: ___________________________________

Services/Health Care Received (check-up, physical therapy, lab work, x-rays, etc.)
 
 
 
 
 
 







If you have any questions about your Medicare or Medicaid charges

  • Call your health care provider. Most are honest and want to correct mistakes.
  • If you still have questions, contact us at:
    Administration on Aging
    330 Independence Ave., SW
    Washington, DC 20201
    Phone: 202-619-0724
    Fax: 202-260-1012
    E-mail: AoAInfo@aoa.gov

Notes

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