The Medical History Builder is a form that you can download and provide to patients. This electronic form is easy to use and will help Survivors put together a summary of their medical history. It helps as they visit other doctors and may mean they won’t have to fill out the same information each time they see a new doctor. Patient data is stored on patients' PCs so they can save and update information when they need to. This will help them keep their medical information updated and easily accessible in one convenient location. They can print and e-mail the data to their doctors.* They can store, update and share their health information from their PC as needed.

Click the link on the right to download this form. The form is a PDF so you'll need Adobe Reader, which can be downloaded from the Adobe site for free.

* Should patients choose to email this form to their physician please note that the Internet is not secure, and that security can only be assured if the transmission and content are encrypted.