Travelers' Electronic Health Record Template 

Sometimes technology fails. Usually at the worst time. Use this format to keep important medical data handy for urgent care situations.

Copy, paste, and reformat in your word processor:

Basic patient data
Full name
Country code(s)
Blood group and type
Marital status
Mother language
Emergency contact—name, relationship to individual and contact information
Passport/ID number
Body weight and height
Spouse name
Employer name
Present medication
Medication name
Prescription period (from—to)
Medication (ATC code)
Medical history
Diagnosis (ICD-10 preferred or ICD-9 moving to SNOMED when and if available)
Allergy (free text now; RxNorm when available)
Smoking and drinking status
Vaccination history
Test report
Major operation history
Laboratory report
Examination report
Travel history
Country code(s)
Date from—to
Family heredity disease history
Father, mother disease
Physician contact
Source of regular medical care, eg, physician, clinic and contact information. 

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