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Reach · Worksheet
Your health records: the worksheet.
Print one for each person. Nobody has to share what they write.
Moraph for Good · Reach
Your health records
Worksheet · moraph.org/commons/sessions/reach/your-health-records
These exercises are for you. Use real or practice details, and nobody has to share their answers.
1 1. A practice request
Fill in a request you could send. To (clinic or hospital): ___. My full name and date of birth: ___. I am asking for a copy of: ___. For the dates: ___. Please send it as (paper, electronic, or to collect): ___. Contact me at: ___. Date of this request: ___.
2 2. Where my records are
List the places that might hold records about you, and how each one takes requests.
| Place (doctor, hospital, pharmacy, lab) | How to ask (portal, form, email, letter) | Date asked | Reply received |
|---|---|---|---|
3 3. My one-page summary
Things to keep on a private summary sheet at home. Tick when done.
- Medicines I take and how often
- Allergies and reactions
- Main conditions
- My doctor’s name and phone number
- Emergency contact
- Where I keep my full records
General information, not advice about your own situation. Free to copy and adapt. moraph.org/commons