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My Health Pocket Guide

Download or order a copy 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.

One large holding one small and one medium-sized purple-outlined figures with purple starsand a purple curved line above them.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.

Five overlapping dark blue circlesThe 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.

 

Gray human figure drawing with white bones.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.

Name____________________________________

I liked to be called____________________________

Date of birth________________________________

Address___________________________________

Phone (Home)___________ (Cell)___________
(Work)____________

E-mail____________________________________

How I communicate best:_______________________

________________________________________

How I like to learn new information or skills:
________________________________________

________________________________________

Questions to ask at a regular appointment:

  • How do you think I am doing?
  • Are there any problems I should know about?
  • Do I need any medical tests? If yes, what kind?
  • Do I need new medication or changes in my medication?
  • If yes, what kind? Are there any side effects?
  • Are there any changes in what I should do day-to-day to take care of myself? If yes, what kind of changes?
  • Are there any changes in what I can or cannot do?
  • If yes, what kind (especially at work or in school)?
  • Do I need another appointment? If yes, when?
  • Is there other information I should remember?
  • Follow-up/What is my next step?

Questions to ask about hospitalization or surgery:

  • Why is this needed?
  • Are there any alternatives or treatments?
  • What will need to be done?
  • What are the risks or possible complications?
  • How long will I be in the hospital?
  • What will happen when I am there?
  • How will I be different after surgery?
  • How will I be the same?
  • Do I need to do anything different to prepare for the surgery and/or hospitalization?
  • Are there any special written instructions I need to have before, during or after?
  • Where do I go, and what do I need to bring?

What I like to do with my time (school, work, hobbies, etc.):

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

This is how I usually feel:

Sad or Worried inside outline of a hand with the thumb pointing down.………………..OK………………..Happy inside outline of hand with thumb pointing up.

.In Pain inside outline of hand with thumb pointing down.……………….OK………………..No Pain inside outline of thumb with thumb pointing up.

My health care needs and concerns:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

My medications (name, amount and when taken):

Write your medications here or in your health care notebook.

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

For additional listings see care plan or health care notebook.

Questions to ask when you are sick:

  • What is wrong?
  • What caused this?
  • What should I do about it?
  • How long will it last?
  • Can I go to work/school?
  • Do I need medicine?
  • Are there any side effects to this medicine?
  • Are any of the medications I already take affected by this new medicine?
  • What if I don’t start feeling better, or I start feeling worse?
  • Are there any changes in what I am supposed to do to take care of myself?
  • Do I need another appointment?
  • Are there any other instructions or information I need to know?
  • Follow-up/What is my next step?

Questions to ask the dentist:

Make sure to tell the dentist if you are afraid, if you gag easily or have trouble keeping your mouth open.

  • What kinds of dental problems do I have?
  • What causes these problems?
  • What can I do to make these problems better or not get any worse?
  • Is there a special toothbrush I should use?
  • Is there a special toothpaste I should use?
  • How often and when should I brush my teeth?
  • Can you please demonstrate how I should brush my teeth?
  • Is there a special mouthwash I should use?
  • How often should I use mouthwash?
  • Can you please show me ways to floss more easily?
  • When should I floss?
  • Are there any changes in my diet you recommend?
  • When do I need another appointment?

My allergies (including latex and/or medication allergies):

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Immunization records:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

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

My Health Care Team

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

Name Specialty Phone Number

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

Name ___________________________________________

Relationship_______________________________________

Phone (Home)____________ (Cell)___________
(Work)___________

E-mail__________________________

Power of Attorney for Health Care:______________________

Guardian: Self_____________ Other (name)_____________

Supported Decision Making Agreement____Yes____No

Information on hospitalizations and surgeries:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

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