Medical Quick Reference

Download your copy of the Medical Form Template. This file will contain a template in Word format as well as in OpenOffice.

If you do not have either Word or OpenOffice, here is a free download of OpenOffice.

If you are on a Mac and have trouble opening .zip files you may need a 3rd party software. Here is a free download of Stuffit.

How to Use the Medical Data Template

All <enclosed> words are entry fields- where you enter your patient information.

The <Patient Name> and <DOB> will automatically print on all sheets. You just have to enter it once. If your patient data spans multiple pages the header information will repeat.

Click on the <field> and enter your patient information.
Enter the first row of data (tabbing through each column).
When you click on tab at the end of the row a new row will appear.
Here are some examples of each section…

Medications: Be sure to include all prescription as well as over the counter medications.

Some helpful abreviations for frequency:

  • PRN indicates you take the medication as needed
  • BID is twice a day
  • TID is three times a day
  • QID is 4 times a day
  • Q# is every # hours ie: Q6 is every 6 hours.
Motril 20/5MG PRN
Prevacid 15MG Solutab BID
Keppra 100MG/ML SOLN Q8

Food: You may not need this section at all if you are not on a special diet or G-Tube. If so just enter N/A and move on to the next section. If you do need this section it should fit bolus, or continuous feeding methods. If you do a combination of the 2, enter additional lines with daily totals per, then on an extra line instead of food name enter Grand Daily Total and sum them up.

Enfamil Lipil 30cc/HR 600cc
Pedialite 60cc BID 120cc
Grand Total 720cc

Allergies: Your doctor will go over the details of the allergic reaction, all you need to do here is indicate if there are any drug allergies and if so, the drug/medication that the patient is allergic to.


Equipment: In this section list out any medical equipment the patient uses. This can be a variety of things.

SuperStand Use daily as tolerate
Zevex Infinity Pump
DeVilBiss Suction
8french caths.

Medical Providers: This area can cover many areas (doctors, therapists, DME, Pharmacies, etc). Depending on the patient you may have a lot of entries for this section.

Dr. Jones Pediatrics (512)555-1234 RN-Jenny
CVS Pharmacy (512)555-2345
DCMC Outpatient Rehab (512)555-3456 PT – Joe
Travis Med DME (512)555-4567 Enteral Supplies
PSA Nursing (512)555-5678 Case Manager- Lynn

Diagnosis: In this section list out all medical diagnosis the patient has been given. This list will very with each patient. A lot of times when asked this on the spot it is hard to come up with everything (or the correct name). This will help to be sure you get them all.

Cerebral Palsy
Seizure Disorder

MAJOR Medical History: This is MAJOR Medical, not ALL medical. Your doctor does not need to know every cold the patient has had, they don’t need to know every well check, they just need the major stuff (Hospital Stays, Procedures, Special Treatments, etc). The date may be a single date is if was an outpatient procedure or it may need to be a date range if it was a hospital admitition.

01/01/10 Dell Children’s Hospital Ear tubes placed
2/1/10-2/3/10 Seton Main Sleep Study
3/1/10-4/5/10 Austin HBOT Hyperbaric Treatments (40-1 hour sessions)