My Health Pocket Guide

Download a PDF of My Health Pocket Guide

The My Health Pocket Guide was developed by Debra Gillman. It was originally printed in 2009, with a fifth printing in 2020.

This publication is designed to be used with Transition to Adult Health Care – A Training Guide in Three Parts and The Workbook for Youth.

The Children and Youth with Special Health Care Needs Program, within the Wisconsin Department of Health Services, Division of Public Health, is supported with funding from the Maternal and Child Health Title V Services Block Grant, Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. This publication was supported by funding from the U.S. Health Resources and Services Administration, Maternal and Child Health Bureau, through grant number 4DOMCO4467-01-03, Wisconsin Integrated Systems for Communities Initiative.

The Waisman Center is dedicated to the advancement of knowledge about human development, developmental disabilities and neurodegenerative diseases. It is one of 9 national centers that encompass both an Intellectual and Developmental Disabilities Research Center designated by the National Institute of Child Health and Human Development, and a University Center for Excellence in Developmental Disabilities (UCEDD) designated by the Administration on Developmental Disabilities.

My Health Pocket Guide

Use this pocket guide and a notebook or folder to keep track of your health care information. Remember, your health information is private.

• Have a separate page for each of your appointments.
• Put the name of the doctor or other health care provider you are seeing and the appointment date at the top of that page.
• Before you go into your appointment, write down how you have been feeling lately, any symptoms of illness and any special concerns you have.
• You may have someone you trust go to the appointment with you. That person can be with you throughout the appointment or just at the beginning or end of the appointment. Then you can still have some time alone with your health care provider.
• Write down information and instructions at your appointment, so you don’t have to try to remember everything. If you need help doing this, just ask your provider or the person you brought with you to help.
• Remember: You can talk with your doctor about any of your health concerns or questions. Your doctor needs to know your true feelings and concerns in order to help you. It is important to ask for information to be repeated or explained again if you do not understand it the first time. You can ask the doctor to write the information out for you, especially if there are medical terms or new words that may be hard to remember. Seeing information can sometimes help.
• Use the questions in this pocket guide to help you at your appointment.

Write down the following:

• • Name
  • I liked to be called
  • Date of birth
  • Address
  • Phone (Home, Cell, and/or Work)
  • E-mail
  • How I communicate best
  • How I like to learn new information or skills
  • My health care needs and concerns
  • My medications (name, amount and when taken). Write your medications here or in your health care notebook.
  • My allergies (including latex and/or medication allergies)
  • Immunization records
  • What I like to do with my time (school, work, hobbies, etc.)
  • This is how I usually feel:

……………OK…………..

.……………OK…………..

For additional listings see care plan or health care notebook.

My Health Care Team

Write the names, specialty, and phone number of your doctors, therapists, other health providers (including pharmacy, equipment and supplies vendor) here or in your health care notebook.

Who helps me with medical decisions and/or follow up:

• Name
• Relationship
• Phone (Home, Cell, and/or Work)
• E-mail
• Power of Attorney for Health Care
• Guardian (self or name of other)
• If you have a Supported Decision Making Agreement
• Information on hospitalizations and surgeries

If you need more room, use your health care notebook.