Medical Record Form / Record Keeping

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Bringing with you all of the medical information you need to share with your doctor before a visit, or before a hospitalization can be very helpful. The attached form can be used as a helpful guide to remembering everything you need to talk to your doctor about.

For many of us with NF2, there is so much information we need to make sure the doctor is aware of, that assuming we would remember it all during the visit is a bad idea, especially if we have surgery or treatment related questions. It is very easy to get overwhelmed when speaking to the doctor due to the amount of information and possible questions and a piece of paper as a guide to make sure we discuss everything that is important, or can give to the doctors or nurses you need to speak to makes visits a lot easier. It can also serve as a good medical record for ourselves to hold onto.

Note: There is no submitting option for this form. This form is for anyone to either fill in to print or save you're your own computer for your own personal records. Same applies to the attached.

Medical Record Form as PDF

1. Your Name:		2. Date:
3. Visit With:		4. Doctor Name:
5. Recent Tests:
Test	Of or For	Facility	Date

6. Doctors and Medical Specialists:
Type of Doctor	Name	Phone #	Address

7: Physical Therapy:
Therapy Type	More Information	Specialist or Facility	Phone

8. Current Prescriptions:
Medication Name:	Dose:	How Often:	For:
		# Per # Per # Per # Per # Per
Additional Prescription Information:
9. Current Supplements:
Supplement Name:	Dose:	How Often:	For:
		# Per # Per # Per # Per # Per
Additional Suppliment Information:
9. Conditions:
Ongoing Health Conditions

New Health Issues or Conditions

Additional Health Condition Information
11. Allergies:
Medication Allergies

Food Allergies

Explain any Special Diet Information:
12. Surgeries or Treatments:
Date	Treatment	More Info





13. Current Medical Concerns:
14. Supplements or Medications you are considering:
15. Questions: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Medical Record Form as PDF

NF2 NYC Support Group, New York
Email: Lori Davila at lori@nf2nycsupport.org
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DISCLAIMER: www.nf2nycsupport.org is not run by medical experts, affiliated with any healthcare organization or any other company. No assurance can be made to the accuracy or completeness of the information provided here, the accuracy of other sites to which this site links, or of sites that link to this site. While we hope the information found on the www.nf2nycsupport.org site is helpful in offering suggestions in topics to discuss with your doctor, information found here should not be considered actual medical advice. Medical advice should always be sought by consultation with a medical professional.