The Clipboard is a patient information form that contains vital health information. This form is a printable version of a patient’s health summary.

Click Clipboard to access the patient information form.

A message may display depending on the type of browser used to view the PHR. If a message displays, it will provide options to open, save or cancel the document. Click Open to view the document.

The PatientClipboard.pdf displays the following sections:

• Patient Information – general patient information
• Insurance Information – primary and secondary insurance information
• Emergency Contact
• Chronic Conditions/Risk Factors
• Immunizations - identified in the last 60 months
• Medication List – medications added to the PHR in the last 120 days
• Inpatient Hospital Visits - identified in the last 48 months
• Problem List – distinct diagnoses identified in the last 48 months
• Medical History – personal, social and family Information