One-Page Health Summary for Your Care Team (Template)

Copy the template below into a document, fill in what you know, add dates, and bring a printed copy to each visit. Update it after anything changes. It is a plain list, so you can also print this page from your browser.

You do not have to fill it in alone. Your records from every portal will have most of the lab results and dates.

The template

• Name and date of birth:
• Date you last updated this page:
• Conditions you have been told you have, and when:
• Medicines and supplements (name, dose, how often, what it is for), including over-the-counter drugs, vitamins and herbal remedies:
• Allergies and bad reactions to medicines:
• Recent lab results (test name, result, date, and the range printed on the lab report), for example A1c, eGFR and UACR if you track them:
• Surgeries, procedures and hospital stays (what, when, where):
• Your doctors and clinics (name, specialty, phone number):
• Your pharmacy (name and phone number):
• Upcoming tests and appointments:
• Your questions for this visit, most important first:

Why these items

The National Institute on Aging suggests bringing a list of everything you take and the dose, the names and phone numbers of the other doctors you see, and your medical records if the doctor does not already have them. It also says to tell the doctor about all your medicines, any drug allergies or reactions, and your pharmacy's phone number, and to put your most important concerns first.

An example

Our sample Care Team Brief shows how one page can lay out results with their dates and the guideline behind each flag. It uses made-up values and is not a real person.

What to do with the files

If you would rather not copy results by hand, Phi Longevity PRISM can build the lab-results part of this page for you. Connect MyChart at participating Epic health systems, or upload your lab reports, and it builds a one-page Care Team Brief with dates and trends. Add your medicines, allergies and questions before you print it. For type 2 diabetes, see our one-page diabetes and kidney summary.

Start free: build my Care Team Brief →

What Phi Longevity PRISM does not do

It does not diagnose, and it does not decide what your results mean for you. It reads lab results today; medicines, diagnoses and allergies are not imported yet, so those lines are yours to fill in. A summary is a tool for your visit, and your doctor decides what you need.