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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... |
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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 |
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List of Health Problems/Conditions |
List of Allergies |
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List of Operations/Surgeries |
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List of Medical Equipment and Supplies |
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Medications |
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Physician Visit: Record #1 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #2 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #3 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #4 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #5 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #6 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #7 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #8 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #9 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #10 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #11 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
Physician Visit: Record #12 |
Date: ________________ Physician/Care Provider: ___________________________________ Weight: ___________________________________ Blood Pressure: ___________________________________ |
If you have any questions about your Medicare or Medicaid charges |
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Notes |
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