Personal Health Care Record Form


Healthcare can be confusing and overwhelming… the Personal Health Care Record sheet better prepares you for medical interactions and increases the effectiveness of appointments. By detailing questions and current symptoms/problems prior to an appointment, you are able to advocate for yourself and ensure each medical interaction is meeting your needs. The sheet also provides an understandable record of visits by having providers clearly write new care plans, follow up/special instructions, and answers to your questions. Bring a healthcare advocate (family member, trusted friend, or paid caregiver) to your appointments to be another set of ears and help you take notes on this form.

Instructions for Use: 

  • Use a copy of this sheet at each health care visit
  • The older adult fills out the following sections prior to the appointment:
  • The provider fills out (or helps the older adult fill out) the following sections during the appointment:
    • Answers/Explanations from the Provider to the Questions/Symptoms/Problems to Address
    • Care Plan/Special Instructions from the Provider
    • Medication Changes/Additions – click here for discussion ideas
    • What permission form do I need to sign for if my family member wants to discuss my health?
  • If a follow up test/procedure is required, the older adult is to use “Possible Questions for Tests/Procedures” as applicable

Click here  to download the Personal Health Care Record Form