Creating a Medical Summary
An editable template to create your own medical summary can be found here.
Creating and using a medical summary
The goals of a medical summary are:
To communicate effectively with your providers
To help you understand your medical situation more clearly
To help family members who might need to help you
There is no standard way that you must write a medical summary. Keep these goals in mind as you tailor this template to meet your needs. For instance, it is fine to add additional notes when it seems appropriate or to use common abbreviations to save space if they are clear to those who need to use this information. If certain information seems completely irrelevant, such as the dose of a multivitamin or a description of your pills, you can leave it out.
Creating a thorough medical summary can seem overwhelming. Do what you can. A little is a lot better than none. The most important information is the medication list. Just a list of the name, dose and frequency of your medications is extremely useful. But so is a list of your health problems, even if you forget a few. Just get started. You can add more information over time. Add information that you were asked about but didn’t know so you’ll have it for next time. Ask your providers to review your summary and suggest details to add.
It is not necessary to print a new copy of the medical summary every time something changes. Handwritten notes of short-term medications such as antibiotics, changes to appointment dates or adjustments of medication doses are perfectly acceptable as long as the information is clear.
Consider keeping a folder of your medical information that you take to every encounter with a provider. Items in the folder could include:
Your medical summary
Copies of medical tests
Discharge instructions
Discharge summaries from hospitalizations
A list of questions to ask your provider
Records you have made at home, such as blood sugar, blood pressure or weight records
Advanced directives and DPOA paperwork
Don’t rely on just one source of information. Have a backup. Medical folders get forgotten or may not be available in an emergency. Phone batteries die. Cell phone service may be spotty in some buildings. Portals may be temporarily unavailable. If you see multiple providers using different systems, the information on one portal may be incomplete. Possible backup methods include:
Take pictures of this information on your phone
Keep a file of this information on your phone
Give a copy of this medical summary to a trusted friend or relative who can send you a picture of the information
Get access to your providers’ portals
Create a Google document or use a medical app
Always consider the risks and benefits before putting your medical information online. These details can reveal a lot about you
Instructions
Note: The examples in these instructions are not intended to suggest a treatment plan for any disease.
The information you need to complete your medical summary can be gathered from a variety of sources, including:
pill bottles
paperwork you receive at the end of a visit to your provider
healthcare portals
asking your provider
Part 1: Name and date
Part 2: Medication list
Part 3: Providers
Part 4: Active medical problems
Part 5: Previous medical problems and surgeries
Part 6: Immunizations
Part 7: Drugs that were stopped due to side effects
Part 8: Significant test results
Part 9: Upcoming tests and plans
Part 10: Questions for providers
A new row can be added to any of the tables in this template by clicking in the last cell of the table (in the lower right-hand corner of the table) and pressing the “tab” key.
Include as much of your name as necessary to distinguish your summary from other family members. For increased security of your information, you do not need to include more information than necessary, such as your last name, your date of birth, or your social security number.
Make a note of the date the information was updated to distinguish it from previous copies and to indicate how old the information is and whether it might be out of date.
Medical Summary for Mary, updated 3/1/26
The medication list is the most important part of your medical summary. Be sure to include everything you are taking currently, including:
Prescribed medications
Over-the-counter medications
Herbal supplements
Vitamins
Creams
Inhalers
Short-term medications such as antibiotics
Medications you only take from time to time
The essential information includes the name of the medication, the dose, and how often it is taken. Other information that can be useful includes:
Both the brand name and generic name
The reason why you take it
Who prescribed the medication
The date started
A description of what the pill looks like
If it makes sense in your situation, it is reasonable to split the list into prescribed, over-the-counter medications, and vitamins, for instance.
Medication List
| Medication | Dose & Frequency | What it is for | Prescriber | Date started | Description |
|---|---|---|---|---|---|
| lisinopril/HTCZ | 20/12.5 mg daily | Blood pressure | Dr. Smith | 2018 | Light brown |
| metformin | 500 mg twice daily | Diabetes | Dr. Smith | 2019 | White, G10 |
| furosemide (Lasix) | 20 mg twice daily | CHF | Dr. Jones | 8/23, increased to twice daily 1/5/26 | Small, white |
| apixaban (Eliquis) | 5 mg twice daily | Atrial fibrillation | Dr. Jones | 12/25 | Pink, oval |
| atorvastatin (Lipitor) | 40 mg daily | High cholesterol | Dr. Jones | 12/25 | White, oblong |
| clopidogrel (Plavix) | 75 mg daily | Stent placed 12/25 | Dr. Jones | 12/25, plan to be off after 1 year | Pink, round |
| tacrolimus cream (Protopic) | Psoriasis | Dr. Wilson | 2020 |
| Inhaler | Dose & Frequency | Prescriber | Date started |
|---|---|---|---|
| Symbicort | 1 puff twice daily | Dr. Smith | 2024 |
| Albuterol | 2 puffs every 4 hours as needed | Dr. Smith | 2024 |
| OTC med | Dose & Frequency | What it is for | Prescriber | Date started |
|---|---|---|---|---|
| Iron | 65 mg daily | Anemia | Dr. Smith | 2024 |
| Vitamin D3 | 1000 units daily | Low vitamin D | Dr. Smith | 2024 |
| Multivitamin | 1 pill daily |
Short-term medications:
Prednisone taper, Augmentin, Z-pack started at Urgent Care on 2/26/26 for pneumonia
List all your providers, what their specialty is, office location or medical group, their contact information, the date of your last visit, and the date and time of your next visit.
Providers
| Name | Specialty | Office location | Phone number | Last appt | Next appt |
|---|---|---|---|---|---|
| J. Smith | Primary | Nifong | 11/6/25 | 3/8/26, 3 pm | |
| H. Jones | Cardiologist | University | 1/30/26 | 4/12/26, 11 am | |
| M. Wilson | Derm | Keene | 2/8/26 | 2/15/27, 2:15 pm | |
| D. Adams | Ophthalmologist | University | 10/1/25 | 6/8/26, 2 pm | |
| G. Allen | GI | GI Associates | 5/1/22 | None |
Active medical problems are the ones that you currently are:
having symptoms of
taking medication for
seeing a provider about
A simple list of diagnoses is good. Even better are details that indicate how severe the disease is or what complications you have had from it.
It often helps to organize the list based on organ system rather than chronologically.
Active Medical Problems
- Hypertension
- Atrial fibrillation
-
Coronary artery disease
- Heart attack 8/19/23 with stent placed in RCA
- Heart attack 12/6/25 with stent placed in LAD
- High cholesterol
-
Congestive heart failure
- Developed after heart attack, 8/23
- EF 20% on echo 8/23, EF was 50% on echo 12/19/25
-
Diabetes mellitus, type II
- Last Hgb A1c = 7.2%
- Complications: peripheral neuropathy, eye, kidney problems
-
Chronic kidney disease
- Last creatinine = 2.2 on 1/6/26
- Asthma
- Psoriasis
-
Iron-deficiency anemia
- Iron level = 6 on 10/5/25
- Hemoglobin = 8.2 on 10/5/25
- Low vitamin D
This includes all major medical problems and all surgeries that you have had in the past that seem to no longer be an active problem. You should include more minor recent issues but then remove them from the list as time goes by.
Previous Medical Problems & Surgeries
- Appendectomy
- Left ovary removed for benign cyst, 2018
- Right breast cancer, lumpectomy 2020, resolved, oncologist was Dr. Martin
- Pneumonia, left upper lobe, hospitalized at University, 2016
- Torn right ACL, 1998
- Acute bronchitis, treated at Urgent Care, 1/24/26
- Pneumonia, treated at University ER, 2/26/26
Many adult immunizations only require one or two doses in your lifetime. Others, such as tetanus, need to be repeated. You should note all dates of immunizations that require a limited series. You should just note the most recent date for immunizations that need to be repeated throughout your lifetime.
Generally, it will be assumed that you received all your childhood immunizations, and these won’t need to be listed. However, in some situations, it may be best to make note of what childhood immunizations were or were not received.
Immunizations
| Immunization | Date |
|---|---|
| Shingles | 1/20 & 4/20 |
| Tdap (tetanus) | 2017 |
| Pneumococcal | 2020 |
| Flu | Fall, 2025 |
| Covid | Fall, 2025 |
People often think of all side effects as “allergic reactions”. However, a true allergic reaction to a medication is taken very seriously by providers and is likely to prevent you from being able to take a large class of medications, one of which might be needed to save your life one day. For instance, amoxicillin is an oral antibiotic that frequently causes diarrhea as a side effect. Even if you had such severe diarrhea that you refuse to ever take amoxicillin again, you should not say you are “allergic” to amoxicillin because this would keep you from getting related antibiotics, including IV antibiotics which will not cause diarrhea.
The best approach is to describe what symptoms the medication caused.
Drugs that were stopped due to side effects
| Name | Date | Problem |
|---|---|---|
| amoxicillin | Diarrhea | |
| metoprolol | 1/2026 | Slow heart rate, lightheadedness, even at lowest dose |
| Bactrim | Anaphylaxis | |
| lisinopril | cough | |
| IV contrast | 2018 | Hives, was able to tolerate for CT scan after pre-treatment in 2024 |
It can be very helpful to keep track of specific test results. Blood tests are very common and it is not necessary to keep copies of all sets of blood test results. You can just record ones that have been significantly abnormal in the past. Sometimes only the most recent test is significant, and sometimes a list of results to show a trend is helpful.
Procedures and imaging tests are much less common and they contain detailed information that can be difficult to summarize adequately. Unless the test was completely normal, the best approach is often to keep a copy of the report.
Significant test results
CT chest, University, 11/25, found lung nodule, see report
CT head, University, 6/24, after fall, normal
Colonoscopy 6/22, normal
EGD 6/22, see report
Cardiac cath 12/6/25, see report
Echo 12/20/25, see report
| Test | Date | Result |
|---|---|---|
| Hemoglobin | 5/8/25 | 10.2 |
| Hgb A1c | 11/1/25 | 7.2% |
| Date | Result |
|---|---|
| 3/5/22 | 0.6 |
| 4/8/23 | 0.8 |
| 3/21/24 | 1.1 |
| 4/12/25 | 1.5 |
| 1/8/26 | 2.2 |
Make a note of anything your provider has suggested should happen in the future.
Upcoming tests and plans:
Dr. Smith to order colonoscopy
Dr. Smith to refer to neurology
CT scan scheduled 4/2/26, 2 pm at University
Likely will stop Plavix 1 year after stent per Dr. Jones
Make a note of questions that you have for providers for upcoming visits. Update this whenever a question comes up. Review it carefully before your next visit and make sure you are prepared with the questions you want answered. Organize the questions based on who you expect will have the answers.
Questions for providers:
Dr. Smith
Schedule a colonoscopy
Review blood pressure record
Dr. Jones
Should I be on both Eliquis and Plavix?
Dr. Wilson
Dr. Smith is concerned I shouldn’t be using tacrolimus cream for so long
Spot on my shoulder