Personal Medical Problem List

Dear Consumer: the Patient Safety Center is posting this new product for your review and comments. This has been developed by a statewide Patient Safety Enhancement Committee of the Department of Health composed of clinicians and public health workers. Our goal is for you to fill out this form with your important medical information.

You should keep a copy with you so it is available if and when you have a health care encounter in the emergency room, the hospital, or your doctor's office. This information includes allergies, medications, and medical conditions. By updating your health information after each encounter, and asking appropriate questions to clarify issues, you can help avoid medical errors and adverse events.

Download in Adobe Portable Document Format (PDF)

Download in Microsoft Word Document Format

Please send any comments to: dxv01@health.state.ny.us

Thank you very much for your help!