This is a nongovernment site brought to you by MedicarePrompts.ai.
This site is currently private and not yet intended for public use.
MedicarePrompts.ai
← Back to Resources
Fillable & Printable Template

Personal Medical Summary

Type directly into each field, then click Print This Form to print or save as a PDF. Your answers are never saved or transmitted — they exist only in your browser while this page is open.

Privacy guarantee: Everything you type stays entirely on your own device — nothing is sent to any server, saved in your browser, or stored anywhere. When you close or refresh this page, all entries are cleared. Print or save as PDF before leaving.

MM / DD / YYYY
e.g. O+
Current address — update after move
Panama City Beach, FL 32408 — after August 20, 2026
Emergency Contacts
Legal Documents on File
Name and phone of your healthcare agent
Yes / No — location of document
Yes / No — location of document
Yes / No — location of document
Medicare
Found on your red, white, and blue Medicare card
MM / YYYY
MM / YYYY
Current Plan (Illinois — leaving August 20, 2026)
Aetna Medicare Value Plan (PPO)
000003-IL000008
Found on your Aetna member ID card
Number on your member ID card
New Florida Plan
To be completed after enrollment — enroll by October 22, 2026
Medicare Advantage / Original Medicare + Medigap / Original Medicare only
Part D Prescription Drug Plan

Fill in your doctors' names, direct phone numbers, and the MyNM portal contact details. Bring this to every new Florida provider appointment.

SpecialtyDoctor namePractice / HospitalPhoneCondition managed
Northwestern Medicine — Key Contacts
MyNM patient portal: nm.org/mychart  |  MyNM team: 855-457-6966
Medical records request: 877-973-2673  |  nm.org/medical-records
Radiology imaging (CD): Request separately — allow 5–7 business days

List all current diagnoses, including chronic conditions, ongoing monitoring needs, and recently resolved issues. Include ICD codes if known.

Diagnosis / conditionYear diagnosedManaging specialistCurrent status

List ALL known allergies — medications, foods, contrast dye, latex, environmental. Include the specific reaction and severity.

Allergen (drug, food, environmental)Reaction / severityAvoid completely?
Yes / No
Yes / No — Location:

Include ALL medications — prescription, over-the-counter, vitamins, supplements, and herbal products.

Medication nameDoseFrequencyRoutePrescribing doctorCondition treated
Pharmacy Information
CVS / Walgreens / Walmart / Other — records transfer nationwide
Name and address — to be completed

Include all surgeries, major procedures, hospitalizations, and any implanted devices (pacemakers, stents, joint replacements, neurostimulators, etc.).

Procedure / surgeryYearHospital / surgeonNotes / implants
Implanted Devices (if applicable)
e.g. Pacemaker, ICD, spinal cord stimulator, stent
Found on your device card — carry this card at all times
Yes / No / Conditional — specify conditions

Enter your most recent key lab values and imaging results. For nephrology: eGFR and creatinine. For cardiology: EF, ECG. For endocrinology: A1C, TSH. For neurology: MRI findings.

Test / imaging studyDateResult / findingOrdered by
Key Values to Highlight for Each Specialist
Date: _______ Value: _______ Trend: Stable / Declining / Improving
Date: _______ Value: _______
Date: _______ Value: _______
Date: _______ Value: _______ (Cardiology)
Date: _______ Value: _______
Date: _______ Study: _______ Key finding: _______
Relationship and condition
Relationship and type
Type and relationship
Relationship and type
Relationship and condition

Highlight anything especially important — ongoing treatment plans, unresolved diagnostic questions, recent changes in condition, or personal care preferences.

Describe any conditions currently under active treatment or close monitoring
List any pending tests, referrals, or diagnoses still being worked up at Northwestern
e.g. cardiac cath report from 2024, neurosurgery op note from 2022, nephrology biopsy results
Anything you want every new provider to know about your care preferences or history
Name, phone, and email of your Northwestern care coordinator or patient navigator

Check off each item before your first appointment with a new Florida provider. Bring originals or certified copies — not just the portal printout.

This document is for provider coordination purposes. Always verify information with your Northwestern Medicine MyNM patient portal.