Personal Health Record: [Your name]
A personal summary of your own health history that you keep and
carry between clinicians: conditions, medications, allergies,
vaccinations, operations and hospital stays, family history, tests
and screenings, care providers and a visit log, plus how to request
copies of your official records (US, UK and EU examples dated
2026-10-30). Based on common personal health record practice.
Replace every [bracketed] value and every row marked Example.
This is a record-keeping format, not medical advice: your clinicians'
records are the official ones, and every decision about diagnosis,
treatment or medication belongs with a qualified health professional.
Document control
| Field | Value |
|---|
| Document ID | [PHR-001] |
| Person | [Full name] (Example: Rafael Okonkwo-Dahl) |
| Date of birth | YYYY-MM-DD |
| Version | [1.0] |
| Last full check | YYYY-MM-DD |
| Next review | YYYY-MM-DD (at least once a year) |
| Classification | Private: health information |
| Shared with | [Names, sections shared] |
Revision history
| Version | Date | Author | Change |
|---|
| 1.0 | YYYY-MM-DD | [@owner] | First version from portal download and pharmacy list |
| 1.1 | YYYY-MM-DD | [@owner] | Example: Added travel vaccinations and new eye prescription |
Contents
1. Emergency summary
| Item | Details |
|---|
| Blood type (if known from a lab report) | [Type, source document] |
| Allergies | [See section 4; list the serious ones here] |
| Long-term conditions | [See section 2] |
| Current medications | [See section 3] |
| Implants or devices | [Example: none / pacemaker / joint replacement, with card location] |
| Emergency contact | [Name, relationship, phone] |
| Main doctor | [Name, practice, phone] |
| Advance directive or treatment wishes | [Exists? Where kept? Who holds a copy?] |
| Organ donation registration | [Status, register] |
2. Conditions
| ID | Condition (as written by clinician) | Diagnosed | By | Status | Notes |
|---|
| CON-01 (Example) | Asthma | YYYY | [GP] | Active, controlled | Reviewed yearly |
| CON-02 (Example) | Fractured left wrist | YYYY-MM | [Hospital] | Resolved | Cast six weeks |
| [CON-NN] | [Condition] | YYYY | [Clinician] | [Active / resolved] | [Notes] |
3. Medications and supplements
| ID | Medicine and strength (as on label) | Instructions (as on label) | Reason (as told by clinician) | Prescriber | Started | Stopped |
|---|
| MED-01 (Example) | [Inhaler name] [strength] | [As on label] | Asthma (CON-01) | [GP] | YYYY-MM | |
| MED-02 (Example) | [Vitamin D] [strength] | [As on label] | Self-bought supplement | n/a | YYYY-MM | |
| [MED-NN] | [Medicine] | [Instructions] | [Reason] | [Prescriber] | YYYY-MM | YYYY-MM |
4. Allergies and adverse reactions
| Substance | Reaction | Severity | Confirmed by | Date | Notes |
|---|
| Example: [Antibiotic name] | Rash | [Mild / moderate / severe] | [GP, allergy test] | YYYY-MM | Recorded in GP record |
| Example: Peanuts | Swelling of lips | Severe | [Allergy clinic] | YYYY-MM | Carries prescribed auto-injector |
| [Substance] | [Reaction] | [Severity] | [Who confirmed] | YYYY-MM | [Notes] |
5. Vaccinations
| Vaccine | Dose | Date | Product or batch (if recorded) | Given by | Proof kept at |
|---|
| Example: Tetanus, diphtheria | Booster | YYYY-MM-DD | [Product, batch] | [Clinic] | Vaccination card |
| Example: Hepatitis A | Dose 1 of [N] | YYYY-MM-DD | [Product, batch] | [Travel clinic] | Portal download |
| [Vaccine] | [Dose] | YYYY-MM-DD | [Product, batch] | [Provider] | [Location] |
Next due, as advised by: [clinician or public health service], on YYYY-MM-DD: [vaccines].
6. Operations, procedures and hospital stays
| Date | Event | Where | Outcome | Follow-up | Letter kept at |
|---|
| YYYY-MM-DD (Example) | Wrist fracture, cast fitted | [Hospital] | Healed | Physiotherapy, 4 sessions | Scanned folder |
| YYYY-MM-DD | [Event] | [Where] | [Outcome] | [Follow-up] | [Location] |
7. Family health history
| Relative | Condition | Age at diagnosis | Notes |
|---|
| Example: Father | Type 2 diabetes | About 55 | |
| Example: Maternal grandmother | [Condition] | [Age] | |
| [Relative] | [Condition] | [Age] | [Notes] |
8. Tests, screenings and measurements
| Date | Test or screening | Result and unit | Reference range (from report) | Clinician's comment | Next due |
|---|
| YYYY-MM-DD (Example) | Blood pressure | [Value] mmHg | [Range on report] | [Comment] | YYYY-MM |
| YYYY-MM-DD (Example) | Eye test | [Prescription] | n/a | New glasses | YYYY-MM |
| YYYY-MM-DD | [Test] | [Result] | [Range] | [Comment] | YYYY-MM |
9. Care providers
| Role | Name and practice | Phone | Patient number (last 4) | Portal | Notes |
|---|
| Main doctor | [Name, practice] | [Phone] | [....] | [Link] | |
| Dentist | [Name, practice] | [Phone] | [....] | | Check-up every [N] months as advised |
| Pharmacy | [Name] | [Phone] | | | |
| Specialist | [Name, speciality] | [Phone] | [....] | | |
| Health insurer or health service | [Name] | [Phone] | [....] | [Link] | |
10. Appointment log
| Date | Provider | Reason | Questions asked | What was decided | Follow-up and date |
|---|
| YYYY-MM-DD (Example) | [GP] | Asthma review | Is my inhaler technique right? | Technique checked, no change | Review in 12 months |
| YYYY-MM-DD | [Provider] | [Reason] | [Questions] | [Decision] | [Follow-up] |
Questions worth asking at most visits:
- What is the name of what you have found, and how is it spelled?
- What are the options, and what happens if I wait?
- Does this change any medicine I already take?
- What should make me come back sooner?
- Where can I read the notes or results from today?
11. Getting copies of your official records
| Jurisdiction | Right and route | Time limit to respond | Check |
|---|
| United States | HIPAA Privacy Rule right of access to your protected health information (45 CFR 164.524) from providers and health plans covered by it | 30 days from the request, one extension of up to 30 more days with a written reason | Current eCFR text |
| United Kingdom | Subject access request (SAR) under UK data protection law; NHS patients can also see much of their GP record through NHS online services | Usually one month; the organisation may sometimes take longer | ICO guidance page |
| European Union | Right of access to personal data under the GDPR (Article 15). The European Health Data Space Regulation (Regulation (EU) 2025/327) entered into force on 26 March 2025; the Commission states that cross-border exchange of patient summaries and ePrescriptions is due to apply from March 2029 | Under the GDPR, one month, extendable by two further months where necessary (Article 12(3)) | European Commission EHDS page, EUR-Lex |
| Request | Sent to | Date sent | Received | Notes |
|---|
| Example: Full GP record | [Practice] | YYYY-MM-DD | YYYY-MM-DD | Portal download |
| [Request] | [Provider] | YYYY-MM-DD | YYYY-MM-DD | [Notes] |
12. References
| Reference | Checked | Use |
|---|
| 45 CFR 164.524, Access of individuals to protected health information, https://www.law.cornell.edu/cfr/text/45/164.524 | Checked 2026-10-30 (LII reproduction of the eCFR) | US right of access and time limit |
| Information Commissioner's Office, Getting copies of your information (SAR), https://ico.org.uk/for-the-public/getting-copies-of-your-information-subject-access-request/ | Checked 2026-10-30 | UK subject access and response time |
| European Commission, European Health Data Space Regulation (EHDS), https://health.ec.europa.eu/ehealth-digital-health-and-care/european-health-data-space-regulation-ehds_en | Checked 2026-10-30 | EHDS entry into force and application dates |
| Regulation (EU) 2016/679 (GDPR), Articles 12(3) and 15, https://eur-lex.europa.eu/eli/reg/2016/679/oj | Named only, check the current text | EU right of access and response time |
| Regulation (EU) 2025/327 (EHDS), https://eur-lex.europa.eu/eli/reg/2025/327/oj | Named only (CELEX 32025R0327 resolves on the Publications Office), check the current text | EHDS regulation number |
Standard and licence note
Based on common personal health record practice and on the public US,
UK and EU sources named in section 12. The structure, text and
examples are original; the person in the examples is fictional. This
is not medical or legal advice: your clinicians' records are the
official record, rules on access to health records differ by country
and change, so check the current official text and ask a qualified
health professional about any health decision. Template licence: MIT.