My Health Journal

(Front Cover)
My Health Journal

(Inside Cover)

Name: (fill in the blank)
Address:
(fill in the blank)
Phone:
(fill in the blank)

My Health Journal is about your health. Your body. You! It's where you can keep your test results and family history, track your healthcare visits, write your health questions, set your health goals and think about a healthy you. If you want, you can bring this journal with you when you visit your healthcare provider.

CONTENTS
My Checkup Challenge...Page 2
My General Health History...Page 6
My Reproductive Health...Page 8
My Emotional Health...Page 10
My Family Health History...Page 11
My Healthy Living...Page 12
My Important Papers...Page 16

This journal was produced by the RICHES (Resources in Communities Help Encourage Solutions) project of the North Carolina Healthy Start Foundation with the support of the North Carolina
GlaxoSmithKline Foundation. North Carolina GlaxoSmithKline Foundation FOR THE ADVANCEMENT OF EDUCATION, SCIENCE AND HEALTH
© 2008 N.C. Healthy Start Foundation

(Page One)

Emergency Contact (fill in the blank)
Phone (fill in the blank)
Phone (fill in the blank)
Local Hospital (fill in the blank)
Phone (fill in the blank)
Healthcare Provider (fill in the blank)
Phone (fill in the blank)
Dentist (fill in the blank)
Phone (fill in the blank)
Mammogram Clinic (fill in the blank)
Phone (fill in the blank)
Eye Doctor (fill in the blank)
Phone (fill in the blank)
Other (fill in the blank)
Phone (fill in the blank)

OTHER IMPORTANT PHONE NUMBERS
TTY for the hearing impaired 1-800-976-1922
The CARE-LINE 1-800-662-7030
TTY for the hearing impaired 1-877-452-2514
North Carolina Coalition Against Domestic Violence 1-888-232-9124
North Carolina Coalition Against Sexual Assault 1-888-737-2272
Alcohol/Drug Council of North Carolina 1-800-688-4232
QuitlineNC 1-800-784-8669
N.C. HIV/AIDS Hotline "Get Real. Get Tested." 1-888-HIV-4-REAL
Planned Parenthood 1-800-230-PLAN
Carolinas Poison Center 1-800-222-1222

(Page Two)

My Checkup Challenge

Checkups find and treat minor problems before they become major ones. Schedule the

PHYSICAL EXAM
You need a physical exam every year to check your overall health. These are some checkups that may be part of your physical exam. Your healthcare provider will let you know which ones you need.

Date (of exam): (fill in the blank)

You and your healthcare provider will talk about many of the subjects in this journal—your health history, your concerns, your habits and your health goals. You may want to go through these pages before your visit. Write down any questions you have. Don't be afraid to ask.
My questions: (fill in the blank)

My healthcare provider’s answers: (fill in the blank)

Blood Pressure Check

Date: (fill in the blank) systolic (fill in the blank) diastolic (fill in the blank)

Date: (fill in the blank) systolic (fill in the blank) diastolic (fill in the blank)

Date: (fill in the blank) systolic (fill in the blank) diastolic (fill in the blank)

Measures the force of your blood when your heart beats (systolic) and when your heart rests (diastolic). High blood pressure can lead to heart attack, stroke, loss of eyesight and kidney damage. High blood pressure usually doesn't have symptoms or signs. Ask if your blood pressure is "normal"or "high."

(Page Three)

Cholesterol Test

Date: (fill in the blank)
Total cholesterol (fill in the blank)

Cholesterol is needed to help your cells grow. But a high level can put you at risk for heart disease. If your level is higher than 200, ask your healthcare provider what you can do to lower it. Ask if you need this test when you schedule your physical exam.

Diabetes ("Blood Sugar") Glucose Test

Diabetes is a disease in which your blood glucose, or blood sugar, level is too high. High blood sugar can harm your heart, kidney, nerves, blood vessels and eyes. Talk to your healthcare provider about your risk for diabetes. Ask if you need a glucose test.

Date: (fill in the blank)
Test results: (fill in the blank)
What the results mean: (fill in the blank)

HIV/AIDS and Sexually Transmitted Infections (STIs) Tests

If you have any of the HIV or STI risk factors listed on page 8, you should be tested. Be sure to talk with your healthcare provider if you are at risk.

Date: (fill in the blank)
Test results: (fill in the blank)

Date: (fill in the blank)
Test results: (fill in the blank)

Date: (fill in the blank)
Test results: (fill in the blank)

(Insert)

Your healthcare provider may ask you questions about your private life: How heavy is your menstrual flow? How many sexual partners have you had? How many pregnancies? Abortions? Miscarriages? Do you use birth control? These questions aren't meant to embarrass you or make you feel bad. Your answers help your healthcare provider know how to better care for you.

(Page Four)

PELVIC EXAM, BREAST EXAM AND PAP TEST

A pelvic exam looks at the health of your ovaries, uterus, vagina and rectum. A breast exam looks for lumps that could be cancer. A pap test looks for cancer of the cervix. You need a pelvic exam, a breast exam and a pap test every 1 to 3 years — your doctor will tell you how often is right for you. You may get these exams as part of your physical exam. Or you may get them from an OB/GYN.

Date: (fill in the blank)
Test results: (fill in the blank)
My questions: (fill in the blank)

My healthcare provider's answers: (fill in the blank)

MAMMOGRAM

You need your first mammogram at age 40. Sooner if you are at high risk for breast cancer. After 40, you need one every year. A mammogram is an X-ray of your breasts that looks for cancer. Talk to your healthcare provider about a mammogram.Your healthcare
provider may have to schedule your mammogram for you.

Date: (fill in the blank)
Test results: (fill in the blank)
My questions: (fill in the blank)

My healthcare provider's answers: fill in the blank)

(Page Five)

EYE EXAM

You need an eye exam every 2 years. You should see your eye doctor more often if your vision changes or if you have high blood pressure, diabetes or heart disease. If you were contacts, you need an eye exam every year.

Date: (fill in the blank)
Test results: (fill in the blank)
My questions: (fill in the blank)

My healthcare provider's answers: fill in the blank)

DENTAL EXAM

You need a dental exam and cleaning every 6 to 12 months.

Date 1: (fill in the blank)
Date 2: (fill in the blank)
My questions: (fill in the blank)

My healthcare provider's answers: fill in the blank)

OTHER TESTS OR CHECKUPS

Test: (fill in the blank)
Date: (fill in the blank)
My questions: (fill in the blank)

My healthcare provider's answers: (fill in the blank)

Test: (fill in the blank)
Date: (fill in the blank)
My questions: (fill in the blank)

My healthcare provider's answers: (fill in the blank)

(Page Six)

MY GENERAL HEALTH HISTORY

It's important to share your health history with your healthcare provider.

MY HEALTH PROBLEMS AND CONCERNE

1. (fill in the blank)

2. (fill in the blank)

3. (fill in the blank)

4. (fill in the blank)

MY SURGERIES AND HOSPITAL STAYS

(table format)

WHY I WAS IN THE HOSPITAL

DATE

HOSPITAL NAME, CITY AND STATE

 

 

 

 

 

 

     
     

MY BLOOD TYPE

Mark the box with your blood type. Don't know it? Ask your healthcare provider to check it for you.

(table format)

O+

O-

AB+

AB-

A+

A-

B+

B-

               

A simple blood test can let you know if you have sickle cell disease or if you can pass the sickle cell gene on to your children. You can be tested for free at your local health department. Call the North Carolina Sickle Cell Syndrome Program (1-866-NC-SCELL) for more information.

(Page Seven)

IMMUNIZATIONS

Vaccines protect you from some diseases. You may not need all the vaccines listed. Ask your healthcare provider. Write down the date you get each shot or dose of vaccine.

VACCINE
DATE
DATE
DATE

Influenza (flu shot)
Need 1 every year!

   

Tetanus/diptheria (Td)
or Tetanus/diptheria/pertussis (Tdap)
Need every 10 years. If you get a deep cut and it's been more than 5 years since your last shot, you may need to get a tetanus booster.

 

Human papilloma virus (HPV)
This dose vaccine is for women younger than 26.

     

Measles, mumps, rubella (MMR)
May need 1 or 2 does depending on when you were last vaccinated for MMR.

     

Varicella ( chicken pox vaccine)
Need 2 doses if you haven't had chicken pox or this vaccine.

   

Hepatitis A
Need 2 doses if you haven't had this vaccine.

   

Hepatitis B
Need 3 doses if you haven't had this vaccine.

     

OTHER IMPORTANT INFO

Broken bones, sprains, pains, and other things I want to tell my healthcare provider about: (fill in the blank)

(Page Eight)

MY REPRODUCTIVE HEALTH

Your physical exam may include a discussion of birth control and sexually transmitted infection (STI) risks, a breast exam and a pelvic exam. Be sure to ask about any concerns you have!

METHODS OF BIRTH CONTROL I HAVE USED (CHECK ALL THAT APPLY)

METHOD
USE NOW USED BEFORE

 

All these methods will help prevent pregnancy. But only abstinence, latex condoms or polyurethane condoms will give you some protection against HIV and other STIs.

For more information on STIs and birth control methods, talk to your healthcare provider or Planned Parenthood (1-800-230-PLAN

 

No sex (abstinence)

   

The pill

   

Nuva Ring

   

The patch

   

Norplant (in your arm)

   

Implanon (in your arm)

   

Depo-Provera

   

IUD

   

Condoms, male

   

Condoms, female

   

Diaphragm

   

Foams, creams

   

Tubes tied (female) or vasectomy (male)

   

Natural family planning/withdrawal

   

Emergency birth control/morning-after pill

   

Men and women 19 years and older may be able to get a free, family planning exam and some types of birth control methods. Call your local health department or talk to your healthcare provider for more information.

HIV/AIDS

HIV/AIDS is increasing among women. You be be at increased risk for HIV infection if you:

Talk to your healthcare provider about ways to get tested.

(Page Nine)

BREAST HEALTH

Early detection is key to surviving breast cancer. Examine your breasts each month. Get to know what "normal" is for you. Then you'll know when your breasts change.

Check Lying Down
Lie down. Place your left arm behind your head. With your right hand, feel the left breast all around using the 3 patterns shown at the right (patterns are a circular motion, an up and down motion from side to side, and an outward motion from the inside or nipple to the outside, on the complete breast). Then switch hands. Put your right arm behind your head. Check your right breast. Check under your arms, too.

Check Standing Up
How do your breasts look when you bend over with your hands on your hips? Look closely.

If you answer "yes" to any of these, make an appointment with your healthcare provider. If you have questions about how to do a breast self-exam, ask your healthcare provider to help you.

BREAST SELF-EXAM AND MENSTRUAL CHART

Use this chart each month. Mark the circle after you do your monthly breast exam. Write in the dates your period begins and ends (if you are menstruating).

JANUARY

FEBRUARY

MARCH

APRIL

Breast exam (check box)

Breast exam (check box)

Breast exam (check box)

Breast exam (check box)

Start: (blank)

Start: (blank)

Start: (blank)

Start: (blank)

End: (blank)

End: (blank)

End: (blank)

End: (blank)

MAY

JUNE

JULY

AUGUST

Breast exam (check box)

Breast exam (check box)

Breast exam (check box)

Breast exam (check box)

Start: (blank)

Start: (blank)

Start: (blank)

Start: (blank)

End: (blank)

End: (blank)

End: (blank)

End: (blank)

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Breast exam (check box)

Breast exam (check box)

Breast exam (check box)

Breast exam (check box)

Start: (blank)

Start: (blank)

Start: (blank)

Start: (blank)

End: (blank)

End: (blank)

End: (blank)

End: (blank)

If you miss your period or have unusually heavy bleeding or painful cramps, call your healthcare provider.

(Page Ten)

MY EMOTIONAL HEALTH

Your feelings also affect your health. Your body can be harmed by long-term emotional stress and pain. Your healthcare provider, local support groups and organizations can help. Call the CARE-LINE at

DEPRESSION?

It's normal to be sad sometimes. But if your "blue mood" doesn't get better with time, you may be depressed. Depression is a serious health problem and needs treatment. If you have been very sad and have 3 or more of the following signs, seek help.

Do You...

Most of the time I feel: (fill in the blank)

Page Eleven

DOMESTIC AND SEXUAL VIOLENCE

Domestic or sexual violence is not your fault. No one deserves to be hurt. Talk to your healthcare provider if you:

Need help NOW? CALL 1-888-232-9124. The North Carolina Coalition Against Domestic Violence can give you information about services in your area.

MY FAMILY HEALTH HISTORY

It is important to tell your healthcare provider about any family history of cancer, stroke, heart disease or mental illness.

HEALTH PROBLEMS CAUSE OF DEATH
(IF APPLIES)

Mother

 

 

Father

 

 

Mother's Parents

 

 

Father's Parents

 

 

Brothers and Sisters

 

 

(Page Twelve)

MY HEALTHY LIVING

A healthier you is easier than you think. How easy? All you need to do is change 1 thing. Just 1 thing. And when you're done and feeling good, change 1 more thing. On and on you go, making yourself healthier by small, easy steps.

Need help picking your 1 thing? Below is a list of good ideas you can chose from. All of these will make you healthier, feel better and will reduce your risk of dying from heart disease—the number one killer of women in the U.S.

1. Get 30 minutes or more of physical activity each day.
Move your body to see big health gains! Walk, dance, ride a bike. Anything that gets you moving can improve your weight, mood and blood pressure.

What 3 things can you do to get more physical activity? For example: Walk before breakfast. Take the stairs. Go dancing on Fridays.

  1. (Fill in the blank)
  2. (Fill in the blank)
  3. (Fill in the blank)

2. Eat healthier.
Eating healthy can go a long way to reducing your risk for heart disease. Get 9 servings of fruits and veggies each day. Eat foods high in fiber. Look for foods that are low in salt, trans fats and saturated fats.

What 3 things can you do to help yourself eat healthier? For example: Make my sandwiches on whole wheat bread. Make sure I always have fruits to snack on.

  1. (Fill in the blank)
  2. (Fill in the blank)
  3. (Fill in the blank)

3. Keep your weight in a healthy range.
(Doing #1 and #2 make this MUCH easier!) Losing weight is really a matter of adding and subtracting. You add fewer calories to your body when you eat healthy, eat less and stay away from fried and fast foods. You subtract calories from your body when you are active.

What 3 foods or drinks can you cut out (or cut back on) to cut calories? For example: Soda, french fries and candy.

  1. (Fill in the blank)
  2. (Fill in the blank)
  3. (Fill in the blank)
(Page Thirteen)

4. Quit smoking and stay away from secondhand smoke.
When you smoke or breathe smoke secondhand, you greatly increase your risk of heart disease and cancer. If you or someone you love needs help quitting, call QuitlineNC (1-800-QUIT-NOW)

Do you want to quit smoking (Select yes or no checkbox)
If yes, list the people you could call for help and support: (Fill in the blank)

5. Drink no more than one alcoholic drink per day.
Alcohol can increae your blood pressure, your risk of stroke and breast cancer and add to your waistline.

If you regularly drink to get drunk, ask yourself why that might be. Many women drink, smoke or use medicines or drugs to deal with stress. If you need help, please contact the CARE-LINE
(1-800-662-7030) or the Alcohol and Drug Council of N.C. (1-800-688-4232).

If you are pregnant or could be pregnant, don't drink at all. Even a little alcohol could harm your baby and cause birth defects.

WHAT I'D MOST LIKE TO CHANGE
If I could change 1 think about my health, it would be...(Fill in the blank)

What good things would happen if I change that 1 thing? (Fill in the blank)

What is stopping me or making it hard for me to change that 1 thing? (Fill in the blank)

Now turn the page...

(Page Fourteen)

PICK 1 THING

You've come with ideas for how your could be healthier. And you've thought about the thing that you would most like to change about your health.

Now it's time for 1 small step.
Pick 1 thing, just 1 thing that you will do for 21 out of the next 28 days.
My 1 thing is: (Fill in the blank)
To do that, I will help myself by: (Fill in the blank)
And if I need more help, I will ask the following friends and family members to help me by: (Fill in the blank)

Date: (fill in the blank)
Did my 1?
Yes- Great Job!
No-(Check box)
Try again tomorrow!

Date: (fill in the blank)
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No-(Check box)
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(Page Fifteen)

DAY 29: LOOKING BACK

Did you check more "Yes" answers than "No" ones?

(Check box) Yes. Terrific! What helped? What else could help? Were there any pitfalls or problems that you want to watch for in the future? (Fill in the blank)

(Check box) No. Don't worry and don't get mad at yourself! Long-term change almost always takes a couple of tries before it "sticks." What did you learn from these 29 days that will help you when you try again? What will help you check more "Yes" answers next time? (Fill in the blank)

WHAT'S NEXT?

First, pat yourself on the back! You tried, and that's huge! Second, decide what you want to do. You can work on your 1 thing for another 28 days. Or you can move on to another 1 thing. It's up to you. You know yourself and when you've truly changed your 1 thing. Whatever you decide, know that life-long healthy change takes one small step at a time.

(Page Sixteen)

MY IMPORTANT PAPERS

You can ask for a copy of your medical records to keep at home. Keep them and other legal papers in a safe place. For example, put them in a folder or envelope in your dresser.

My medical records - stored where?

My family's medical records - stored where?

My health insurance information (Insurance carrier, policy number, group number) - stored where?

Other important papers (list) - stored where?

Tow very important documents you may want to learn more about are the Health Care Power of Attorney and the Last Will and Testament. A Health Care Power of Attorney allows someone else to make medical decisions for you when you can't make them yourself. A Last Will and Testament tells who you want to have custody of your minor children and your property after you die.

(Last Page)

For more information and an online version of this journal (My Health e-journal), check out the NC Healthy Start Foundation website! www.NCHealthyStart.org/eJournal and www.mamasana.org (en español)

My thoughts about my health: (Fill in the blank)

(Back Page)

North Carolina Healthy Start Foundation logo

North Carolina GlaxoSmithKline Foundation for the advancement of education, science and health