phc

Personal Health Code (PHC)

Last Updated: [YYYY-MM-DD] Version: 1.0 Data Integrity: All values from original reports preserved

📊 QUICK REFERENCE DASHBOARD

Critical Status Indicators

Category	Current Status	Risk Level	Action Required	Last Updated
Cardiovascular Risk	[Value]	[🔴/🟠/🟡/🟢]	[Action needed]	[Date]
Blood Pressure	[SBP/DBP mmHg]	[🔴/🟠/🟡/🟢]	[Action needed]	[Date]
Glucose Control	[HbA1c %]	[🔴/🟠/🟡/🟢]	[Action needed]	[Date]
BMI/Weight	[BMI kg/m²]	[🔴/🟠/🟡/🟢]	[Action needed]	[Date]

Risk Level Key:

🔴 Critical/Very High - Immediate medical attention or aggressive intervention
🟠 Moderate/High - Active management required
🟡 Borderline/Elevated - Lifestyle modification + monitoring
🟢 Normal/Optimal - Maintain current approach

Active Medications

Medication	Dose	Frequency	Start Date	Indication	Next Review
[Medication]	[Dose]	[QD/BID]	[Date]	[Reason]	[Date]

Upcoming Actions

Priority	Action	Due Date	Status
🔴 High	[Action description]	[Date]	⏳
🟠 Medium	[Action description]	[Date]	⏳
🟡 Low	[Action description]	[Date]	⏳

Status Key: ✅ Complete

🔄 In Progress

⏳ Pending

❌ Overdue

Title I: Personal Profile

§1.01 Basic Information

Full Name: [Family Name] [Given Name] ([中文名])
Date of Birth: [YYYY-MM-DD]
Age: [XX] years (as of [YYYY-MM-DD])
Sex: [Male/Female]
Blood Type: [A/B/AB/O] [+/-]
Allergies: [Known drug allergies, or “None known (NKDA)”]

§1.02 Contact & Emergency

Primary Phone: [Phone number]
Email: [Email address]
Emergency Contact: [Name, Relationship, Phone]
Primary Care Physician: [Dr. Name], [Hospital/Clinic Name]

§1.03 Medical Identifiers

Medical Record Number: [MRN]
Primary Hospital: [Hospital Name]
Address: [Hospital Address]
Phone: [Hospital Phone]

Title II: Vital Signs & Anthropometrics

§2.01 Height

Date	Value (cm)	Source	Notes
[Date]	[Value]	[Lab]	—

Current: [Value] cm (as of [Date])

§2.02 Weight & BMI

Date	Weight (kg)	BMI	Source	Notes
[Date]	[Value]	[XX]	[Lab]	[Notes]

Current: [Weight] kg, BMI [Value] (as of [Date]) Trend: [Stable/Increasing/Decreasing] Target: BMI 18.5-24.9 (normal range)

§2.03 Blood Pressure

Date	Systolic (mmHg)	Diastolic (mmHg)	Source	Position	Time	Notes
[Date]	[Value]	[Value]	[Lab]	[Seated]	[AM/PM]	[Notes]

Current: [SBP]/[DBP] mmHg (as of [Date]) Reference: <120/<80 mmHg (optimal), <130/<80 mmHg (normal) Trend: [Consistent/Variable]

§2.04 Body Temperature

Date	Temp (°C)	Method	Source	Notes
[Date]	[Value]	[Oral]	[Lab]	[Notes]

Reference: 36.5-37.2°C (oral)

§2.05 Body Composition (if available)

Date	Body Fat %	Muscle Mass (kg)	BMR (kcal/day)	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Reference: Body Fat (Male): 10-20% (fit), 20-25% (average)

§2.06 Respiration Rate (呼吸频率)

Date	RR (breaths/min)	Source	Notes
[Date]	[Value]	[Lab]	[Notes]

Reference: 12-20 breaths/min (adult)

Title III: Hematology (血液系统)

§3.01 Complete Blood Count (CBC)

§3.01(a) Red Blood Cells

Date	RBC (×10¹²/L)	Hemoglobin (g/L)	Hematocrit (L/L)	MCV (fL)	MCH (pg)	MCHC (g/L)	RDW (%)	Source
[Date]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Lab]

Current: RBC [Value]×10¹²/L, Hgb [Value] g/L, Hct [Value] L/L (as of [Date]) Reference (Male): RBC 4.3-5.8, Hgb 130-175, Hct 0.40-0.50 Trend: [Notes]

§3.01(b) White Blood Cells

Date	WBC (×10⁹/L)	Neutrophils (×10⁹/L)	Lymphocytes (×10⁹/L)	Monocytes (×10⁹/L)	Eos (×10⁹/L)	Bas (×10⁹/L)	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Current: WBC [Value]×10⁹/L, Neutrophils [Value]×10⁹/L (as of [Date]) Reference: WBC 3.5-9.5, Neutrophils 1.8-6.3×10⁹/L

§3.01(c) Platelets

Date	PLT (×10⁹/L)	MPV (fL)	Source	Notes
[Date]	[Value]	[Value]	[Lab]	[Notes]

Current: PLT [Value]×10⁹/L, MPV [Value] fL (as of [Date]) Reference: PLT 125-350, MPV 6.0-11.0 fL

Title IV: Metabolic Panel (代谢指标)

§4.01 Glucose Metabolism

Date	Fasting Glucose (mmol/L)	HbA1c (%)	OGTT 2h (mmol/L)	Fructosamine	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Current: FBG [Value] mmol/L, HbA1c [Value]% (as of [Date]) Reference: FBG 3.9-6.1 mmol/L, HbA1c <5.7% (normal), 5.7-6.4% (prediabetes), ≥6.5% (diabetes) Risk Assessment: [Normal/Prediabetes/Diabetes]

§4.02 Electrolytes

Date	Na+ (mmol/L)	K+ (mmol/L)	Cl- (mmol/L)	Ca²⁺ (mmol/L)	Mg²⁺ (mmol/L)	PO₄³⁻ (mmol/L)	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Reference: Na+ 135-145, K+ 3.5-5.3, Cl- 96-106, Ca²⁺ 2.15-2.55, Mg²⁺ 0.7-1.05, PO₄³⁻ 0.81-1.45 mmol/L

§4.03 Acid-Base Balance

Date	CO₂ (mmol/L)	Anion Gap	pH	Source	Notes
[Date]	[Value]	[Value]	[Val]	[Lab]	[Notes]

Reference: CO₂ 23-29 mmol/L, Anion Gap 8-16 mmol/L, pH 7.35-7.45

Title V: Hepatic Function (肝功能)

§5.01 Liver Enzymes

Date	ALT (U/L)	AST (U/L)	GGT (U/L)	ALP (U/L)	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Current: ALT [Value], AST [Value], GGT [Value], ALP [Value] U/L (as of [Date]) Reference (Male): ALT 5-40, AST 8-40, GGT 8-60, ALP 40-150 U/L AST/ALT Ratio: [Calculate]

§5.02 Bilirubin & Protein

Date	Total Bili (μmol/L)	Direct Bili (μmol/L)	Total Protein (g/L)	Albumin (g/L)	Globulin (g/L)	A/G Ratio	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Reference: Total Bili 5-21 μmol/L, Total Protein 60-80 g/L, Albumin 35-55 g/L, A/G Ratio 1.2-2.5

§5.03 Liver Function Tests (Synthetic)

Date	PT (sec)	INR	Cholinesterase (U/L)	Source	Notes
[Date]	[Value]	[Val	[Value]	[Lab]	[Notes]

Reference: PT 11-13 sec, INR 0.9-1.2, Cholinesterase 4000-12000 U/L

Title VI: Renal Function (肾功能)

§6.01 Kidney Markers

Date	Creatinine (μmol/L)	Urea (mmol/L)	eGFR (mL/min/1.73m²)	Cystatin C (mg/L)	Uric Acid (μmol/L)	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Current: Creatinine [Value] μmol/L, eGFR [Value] mL/min/1.73m² (as of [Date]) Reference (Male): Creatinine 59-104 μmol/L, Urea 2.9-8.2 mmol/L, eGFR >90, Uric Acid 208-428 μmol/L CKD Stage: [Normal/Stage 1-5]

§6.02 BUN/Creatinine Ratio

Date	BUN (mg/dL)	Creatinine (mg/dL)	BUN/Cr Ratio	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Reference: BUN/Cr Ratio 10-20 (normal)

§6.03 Homocysteine (同型半胱氨酸)

Date	Homocysteine (μmol/L)	Source	Notes
[Date]	[Value]	[Lab]	[Notes]

Reference: <15 μmol/L (normal), >15 (elevated CV risk)

Title VII: Lipid Profile (血脂)

§7.01 Cholesterol Panel

Date	Total Chol (mmol/L)	LDL-C (mmol/L)	HDL-C (mmol/L)	Triglycerides (mmol/L)	TC/HDL Ratio	Non-HDL-C	Source
[Date]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Lab]

Current: TC [Value], LDL [Value], HDL [Value], TG [Value] mmol/L (as of [Date]) Reference: TC <5.2, LDL <3.4, HDL >1.0 (M) / >1.3 (F), TG <1.7 mmol/L Risk Category: [Low/Borderline/High/Very High]

§7.02 Advanced Lipids

Date	Lp(a) (mg/L)	ApoB (g/L)	ApoA1 (g/L)	ApoB/ApoA1	Remnant Chol	sdLDL	Source
[Date]	[Value]	[Value]	[Value]	[Value]	[Value]	[Val]	[Lab]

Reference: Lp(a) <300 mg/L (<30 mg/dL), ApoB <1.08 g/L, ApoB/ApoA1 <0.9 (M) / <0.8 (F)

Title VIII: Endocrine (内分泌)

§8.01 Thyroid Function

Date	TSH (mIU/L)	FT4 (pmol/L)	FT3 (pmol/L)	T3 (nmol/L)	T4 (nmol/L)	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Reference: TSH 0.27-4.20 mIU/L, FT4 12-22 pmol/L, FT3 3.1-6.8 pmol/L

§8.02 Sex Hormones

Date	Testosterone (nmol/L)	Free T	SHBG (nmol/L)	E2 (pmol/L)	LH	FSH	Source	Notes
[Date]	[Value]	[Val]	[Value]	[Value]	[]	[]	[Lab]	[Notes]

Reference (Male): Testosterone 8.6-29 nmol/L, SHBG 13-71 nmol/L

§8.03 Adrenal & Other

Date	Cortisol (nmol/L)	DHEA-S	ACTH	Insulin (μIU/mL)	C-Peptide	Source	Notes
[Date]	[Value]	[Val]	[]	[Value]	[Value]	[Lab]	[Notes]

§8.04 Bone & Parathyroid

Date	PTH (pg/mL)	Vitamin D (nmol/L)	Calcitonin	Osteocalcin	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Reference: PTH 15-65 pg/mL, Vitamin D 75-250 nmol/L (sufficient: >75)

Title IX: Immunology & Serology (免疫血清)

§9.01 Inflammatory Markers

Date	CRP (mg/L)	hs-CRP (mg/L)	ESR (mm/hr)	Ferritin (μg/L)	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

Reference: CRP <10 mg/L, hs-CRP <1.0 (low CV risk) / 1-3 (moderate) / >3 (high), ESR <15 mm/hr (M), Ferritin 30-400 μg/L (M)

§9.02 Infectious Disease Screening

Date	HBsAg	Anti-HBs	Anti-HCV	Anti-HIV	RPR/VDRL	Source	Notes
[Date]	[+/-]	[+/-]	[+/-]	[+/-]	[+/-]	[Lab]	[Notes]

§9.03 Autoimmune Markers (if applicable)

Date	ANA	RF	Anti-CCP	Source	Notes
[Date]	[]	[]	[]	[Lab]	[Notes]

§9.04 Immunoglobulins

Date	IgG (g/L)	IgA (g/L)	IgM (g/L)	IgE (IU/mL)	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

§9.05 Tumor Markers

Date	CEA	CA 19-9	CA 125	AFP	PSA (M)	CA 15-3 (F)	Source	Notes
[Date]	[]	[]	[]	[]	[]	[]	[Lab]	[Notes]

Reference: CEA <5.0 ng/mL (non-smoker), PSA <4.0 ng/mL, AFP <20 ng/mL

Title X: Urinalysis (尿液检查)

§10.01 Physical & Chemical Properties

Date	Color	Clarity	pH	SG	Protein	Glucose	Ketones	Blood	Source	Notes
[Date]	[Type]	[Clear]	[pH]	[Val]	[+/-]	[+/-]	[+/-]	[+/-]	[Lab]	[Notes]

Reference: pH 4.5-8.0, SG 1.005-1.030, Protein/Glucose/Ketones/Blood: Negative

§10.02 Microscopic (if abnormal)

Date	RBC/HPF	WBC/HPF	Casts	Crystals	Bacteria	Epithelial	Source	Notes
[Date]	[Count]	[Count]	[Ty]	[Type]	[+/-]	[Few/Many]	[Lab]	[Notes]

§10.03 24-Hour Urine Collection (if performed)

Date	Volume (mL)	Creatinine	Protein	Microalbumin	Source	Notes
[Date]	[Value]	[Value]	[Value]	[Value]	[Lab]	[Notes]

§10.04 Urine Microalbumin/Creatinine Ratio (UACR) (尿微量白蛋白/肌酐比)

Date	UACR (mg/g)	Category	Source	Notes
[Date]	[Value]	[Normal]	[Lab]	[Notes]

Reference: <30 mg/g (normal), 30-300 (microalbuminuria), >300 (macroalbuminuria)

Title XI: Imaging & Diagnostics (影像诊断)

§11.01 Chest X-Ray

Date	Findings	Impression	Radiologist	Source	Report Location
[Date]	[Lungs/heart/bones/etc]	[Normal]	[Dr. Name]	[Lab]	[File path]

§11.02 Abdominal Ultrasound

Date	Liver	GB	Pancreas	Spleen	Kidneys	Other	Radiologist	Source	Report Location
[Date]	[Nor]	[]	[]	[]	[]	[]	[Dr. Name]	[Lab]	[File path]

§11.03 Cardiac Imaging

Echocardiography (超声心动图)

Date	LVEF (%)	LA (mm)	LV (mm)	Valves	Other Findings	Cardiologist	Source	Report Location
[Date]	[Value]	[Value]	[Value]	[Normal/Abn]	[Notes]	[Dr. Name]	[Lab]	[File path]

Reference: LVEF >55% (normal systolic function)

Cardiac CT / Calcium Score

Date	Calcium Score	CAC Percentile	Interpretation	Radiologist	Source	Report Location
[Date]	[Agatston]	[Percentile]	[Risk level/desc]	[Dr. Name]	[Lab]	[File path]

CAC Score Interpretation:

0: No calcification (very low risk)
1-100: Mild calcification (low-moderate risk)
101-400: Moderate calcification (moderate-high risk)
400: Extensive calcification (high risk)

§11.04 Bone Density (DEXA Scan)

Date	Site	BMD (g/cm²)	T-Score	Z-Score	Diagnosis	Source	Report Location
[Date]	[Lumb]	[Value]	[Value]	[Value]	[Normal]	[Lab]	[File path]

T-Score: ≥-1.0 (normal), -1.0 to -2.5 (osteopenia), ≤-2.5 (osteoporosis)

§11.05 Other Imaging

Date	Type	Body Part	Findings	Radiologist	Source	Report Location
[Date]	[MRI/CT/US/etc.]	[Part]	[Notes]	[Dr. Name]	[Lab]	[File path]

Title XII: Cardiovascular (心血管)

§12.01 Electrocardiogram (ECG)

Date	Rate (bpm)	Rhythm	Axis	Intervals (PR/QRS/QT)	Interpretation	Cardiologist	Source
[Date]	[Value]	[Sinus/other]	[Normal/Ax]	[ms/ms/ms]	[Normal/Abn]	[Dr. Name]	[Lab]

§12.02 Stress Test

Date	Type	Max HR	BP Response	ST Changes	METS	Duke Score	Conclusion	Cardiologist	Source
[Date]	[Treadmill/P]	[bpm]	[Normal]	[Yes/No]	[X]	[Score]	[Neg/Pos]	[Dr. Name]	[Lab]

§12.03 Cardiac Biomarkers

Date	Troponin I (ng/L)	CK-MB	BNP (pg/mL)	NT-proBNP	Source	Notes
[Date]	[Value]	[Val]	[Value]	[Value]	[Lab]	[Notes]

Reference: Troponin I <15 ng/L (low risk), BNP <100 pg/mL (unlikely HF)

§12.04 Peripheral Vascular

Date	ABI (Ankle-Brachial Index)	Carotid Ultrasound	Findings	Source
[Date]	[Value]	[IMT mm / plaques]	[Notes]	[Lab]

ABI Reference: 0.9-1.3 (normal), <0.9 (PAD)

Title XIII: Medications & Supplements (药物补充剂)

§13.01 Current Medications

[Medication Name]

Generic Name: [Name] Brand Name: [Brand] Classification: [Drug class]

Parameter	Details
Dosage	[Dose] [Route] [Frequency]
Start Date	[YYYY-MM-DD]
Indication	[Condition being treated]
Prescribing Physician	[Dr. Name]
Side Effects to Monitor	[List potential adverse effects]
Lab Monitoring Required	[Labs needed, frequency]
Response Tracking	[How to assess effectiveness]
Interactions	[Known drug/food interactions]
Special Instructions	[Timing, food restrictions, etc.]

Medication Response Tracking:

Date	Clinical Response	Side Effects	Lab Results	Dose Adjustments	Notes
[Date]	[Effect]	[None/list]	[Values]	[Changed to]	[Notes]

Repeat §13.01 subsection for each current medication

§13.02 Current Supplements

Supplement	Dose	Frequency	Start Date	Indication	Brand	Notes
[Vitamin D]	[1000 IU]	[QD]	[Date]	[Deficiency]	[Br]	[Notes]
[Omega-3]	[1000mg EPA/DHA	[QD]	[Date]	[CV health]	[Br]	[Notes]
[Multivitamin]	[1 tablet]	[QD]	[Date]	[General health	[Br]	[Notes]
[Plant sterols]	[2g]	[QD]	[Date]	[LDL reduction]	[Br]	[Notes]
[Other supplement]	[Dose]	[Freq]	[Date]	[Reason]	[Br]	[Notes]

§13.03 Discontinued Medications

Medication	Dosage	Start Date	End Date	Duration	Reason for D/C	Outcome	Notes
[Name]	[Dose/Fx]	[Date]	[Date]	[X mo]	[Ineffective/AE/Complete]	[Outcome notes]	[Notes]

§13.04 Medication Allergies & Adverse Reactions

Substance	Reaction Type	Severity	Date Identified	Confirmed By	Notes
[Drug name	[Rash/Anaphylaxis/etc.]	[Mild/Moderate/Severe]	[Date]	[Dr. Name]	[Notes]

NKDA: No Known Drug Allergies (check if applicable ☐)

Title XIV: Medical History (病史)

§14.01 Chronic Conditions

Condition	Diagnosis Date	Severity	Current Status	Managing Physician	Notes
[Hypertension]	[YYYY]	[Mild/Mod/Sv]	[Controlled]	[Dr. Name]	[Notes]

§14.02 Surgical History

Date	Procedure	Indication	Surgeon	Hospital	Complications	Outcome	Notes
[Date]	[Procedure name/type]	[Reason]	[Dr. Name]	[Name]	[None/list]	[Good]	[Notes]

§14.03 Hospitalizations

Admission Date	Discharge Date	Hospital	Primary Diagnosis	Length of Stay	Procedures	Complications	Discharge Summary
[Date]	[Date]	[Name]	[Dx]	[X days]	[Proc]	[None/list]	[Summary/file]

§14.04 Major Illnesses

Year	Illness/Condition	Treatment	Resolved?	Notes
[Year]	[Name]	[Tx given/none]	[Y/N]	[Notes]

§14.05 Accidents & Injuries

Date	Type of Injury	Cause	Treatment	Sequelae	Notes
[Date]	[Injury]	[Accident	[Tx]	[Long-term FX]	[Notes]

Title XV: Family History (家族史)

§15.01 First-Degree Relatives (Parents, Siblings, Children)

Relative	Relationship	Age (or Age at Death)	Living?	Major Health Conditions	Age at Diagnosis	Notes
[Name]	[Father/etc]	[XX] / [died at XX]	[Y/N]	[HTN, DM, CVD, Cancer type, etc.]	[Age]	[Notes]

§15.02 Second-Degree Relatives (Grandparents, Aunts, Uncles)

Relative	Relationship	Age (or Age at Death)	Living?	Major Health Conditions	Age at Diagnosis	Notes
[Name]	[Grandfather/etc]	[XX] / [died at XX]	[Y/N]	[Conditions]	[Age]	[Notes]

§15.03 Genetic Risk Summary

Cardiovascular Disease:

Family history: [Positive/Negative]
Premature CVD (<55 M / <65 F): [Y/N]
Notes: [Details]

Diabetes:

Family history: [Positive/Negative]
Type 1 / Type 2
Notes: [Details]

Cancer:

Family history: [Positive/Negative]
Types: [Breast, Colon, Prostate, etc.]
Notes: [Hereditary patterns?]

Other Hereditary Conditions:

Title XVI: Immunization Records (疫苗接种)

§16.01 Routine Vaccinations

Vaccine	Date	Dose #	Lot Number	Manufacturer	Site	Administrator	Next Due	Notes
Influenza	[YYYY-MM]	Annual	[Lot]	[Mfr]	[LA]	[Clinic]	[Next year]	[Notes]
COVID-19	[YYYY-MM]	[1-5]	[Lot]	[Pfizer/Mod]	[LA]	[Clinic]	[Per CDC]	[Notes]
Tetanus/Diphtheria	[YYYY-MM]	Boost	[Lot]	[Mfr]	[IM]	[Clinic]	[+10 years]	[Notes]
Hepatitis B	[YYYY-MM]	[1-3]	[Lot]	[Mfr]	[IM]	[Clinic]	[Complete]	[Notes]
Pneumococcal (PCV)	[YYYY-MM]	[1-2]	[Lot]	[Mfr]	[IM]	[Clinic]	[Per CDC]	[Notes]
Shingles (Shingrix)	[YYYY-MM]	[1-2]	[Lot]	[GSK]	[IM]	[Clinic]	[Complete]	[Notes]
MMR	[Childhood	[1-2]	[Lot]	[Mfr]	[SC]	[Clinic]	[Lifetime]	[Notes]

§16.02 Travel Vaccinations

Vaccine	Date	Dose #	Destination	Lot Number	Next Due	Notes
[Yellow Fever]	[YYYY-MM]	[1]	[Country]	[Lot]	[+10 years]	[Notes]
[Typhoid]	[YYYY-MM]	[1]	[Country]	[Lot]	[+2 years]	[Notes]

§16.03 Antibody Titers (if tested)

Vaccine/Antigen	Date Tested	Titer Result	Immune?	Notes
[Hep B Surface]	[Date]	[Value]	[Y/N]	[Notes]
[Varicella]	[Date]	[Value]	[Y/N]	[Notes]

Title XVII: Lifestyle & Risk Factors (生活方式)

§17.01 Tobacco Use

Status: [Never smoker / Former smoker / Current smoker]
If former: Quit date [YYYY-MM], pack-years [X]
If current: Packs per day [X], years smoking [X], pack-years [X]
Cessation attempts: [History of quit attempts]
Notes: [E-cigarettes, vaping, other tobacco]

§17.02 Alcohol Consumption

Frequency: [Never / Occasional / Weekly / Daily]
Amount: [X standard drinks per week]
Type: [Beer / Wine / Spirits / Mixed]
Pattern: [Social only / Regular / Binge drinking]
AUDIT-C Score: [Calculate if applicable]
Notes: [Any concerns, changes over time]

§17.03 Physical Activity & Exercise

Date Updated	Type of Exercise	Frequency	Duration	Intensity	Notes
[Date]	[Aerobic/Strength/Flex/etc.]	[X days/week]	[X min/session]	[Light/Mod/Vig	[Notes]

Weekly Totals:

Aerobic: [XXX] min/week
Strength training: [X] days/week
Meets guidelines? [Yes/No] (150 min moderate or 75 min vigorous aerobic + 2 days strength)

§17.04 Diet & Nutrition

Dietary Pattern: [Mediterranean / DASH / Western / Asian / Vegetarian / Vegan / Other: __]

Daily Intake Estimates:

Vegetables: [X] servings/day
Fruits: [X] servings/day
Whole grains: [X] servings/day
Protein sources: [Types and frequency]
Dairy: [X] servings/day
Added sugars: [Estimate]
Sodium: [Low / Moderate / High]
Saturated fat: [% of calories]
Fiber: [X]g/day (goal: 25-35g)

Dietary Restrictions: [None / Allergies / Religious / Preference: __]

Supplements: [See Title XIII § 13.02]

§17.05 Sleep

Average hours per night: [X] hours
Quality: [Excellent / Good / Fair / Poor]
Sleep disorders: [None / Insomnia / Sleep apnea / Restless legs / Other: __]
Snoring: [Yes/No/Unknown]
Sleep study performed: [Date, if applicable]
CPAP use: [Yes/No], compliance [%]
Notes: [Sleep hygiene practices, shift work]

§17.06 Stress & Mental Well-Being

Perceived stress level: [Low / Moderate / High]
Major stressors: [Work / Family / Financial / Health / Other: __]
Coping mechanisms: [Exercise / Meditation / Therapy / Social support / Other: __]
Mental health history: [See Title XX]
Notes: [Stress management interventions, relaxation techniques]

§17.07 Occupational & Environmental Exposures

Occupation: [Job title/description]
Exposures: [Chemicals / Radiation / Noise / Dust / Asbestos / Other: __]
Personal protective equipment use: [Yes/No/Details]
Occupational health surveillance: [Exams, monitoring]
Environmental concerns: [Home location, air/water quality]
Notes: [Past exposures, work-related injuries]

Education level: [Highest degree attained]
Employment status: [Employed full-time / part-time / Unemployed / Retired / Student]
Health insurance: [Type, coverage details]
Housing: [Stable / Unstable / Homeless]
Food security: [Secure / Insecure]
Transportation: [Reliable access / Barriers]
Social support network: [Strong / Moderate / Limited]
Notes: [Barriers to healthcare access, community resources]

Title XVIII: Genomics & Genetic Testing (基因检测)

§18.01 Genetic Testing Overview

Test Type	Date	Laboratory	Sample ID	Report Location
[Comprehensive Genomic Panel]	[Date]	[Lab name]	[ID]	processed/[person]/genetic-reports/[FN]
[Targeted gene panel]	[Date]	[Lab name]	[ID]	[File path or URL]

Testing Scope:

Ancestry Analysis 祖源分析
Health Risk Assessment 健康风险
Hereditary Disease Carrier Screening 遗传病携带
Pharmacogenomics 药物基因组学
Nutrition & Metabolism 营养代谢
Exercise Genetics 运动基因
Genetic Traits 遗传特征

Detailed Report: [Link to processed/[person]/genetic-reports/YYYY.MMDD.md]

§18.02 Pathogenic/Likely Pathogenic Variants

Gene	Variant (HGVS)	Classification	Inheritance	Associated Condition	Clinical Action Required
[BRCA1]	[c.123A>G]	[Pathogenic/LP]	[Autosomal Dominant	[Breast/Ovarian CA]	[Screening protocol]

If no pathogenic variants: “No pathogenic or likely pathogenic variants detected”

§18.03 Pharmacogenomics

Key Drug Metabolism Genes:

Gene	Alleles Detected	Phenotype	Clinical Impact
CYP2C19	[1/2]	[IM/PM/NM/RM/UM]	[Clopidogrel, PPIs]
CYP2D6	[1/4]	[IM/PM/NM/RM/UM]	[Opioids, antidepressants]
CYP2C9	[1/3]	[IM/PM/NM]	[Warfarin]
SLCO1B1	[rs4149056 T/T]	[Normal/Intermediate	[Statin myopathy risk: Low/High]
VKORC1	[rs9923231 A/G]	[Normal/Sensitive]	[Warfarin dose: Standard/Reduced]

Drug-Specific Recommendations:

Drug Category	Genetic Finding	Recommendation
[Clopidogrel 氯吡格雷]	[CYP2C19 2/2]	🚫 Avoid, use alternative (e.g.,	[Warfarin 华法林]	[VKORC1 AG + CYP2C9 *1]	⚠️ Start with lower dose

See Full Pharmacogenomic Report: [File link]

§18.04 Ancestry & Traits

Ancestry Composition:

East Asian: [XX]%
European: [XX]%
Other: [XX]%

Haplogroups:

Paternal (Y-DNA): [O2a / R1b / etc.]
Maternal (mtDNA): [D4a / H1a / etc.]

Notable Physical Traits:

Blood type: [A/B/AB/O] [+/-]
APOE genotype: [ε3/ε3] (Alzheimer’s risk: [Average/Increased])
Lactose tolerance: [Tolerant/Intolerant]
Alcohol flush reaction: [Yes/No]
Caffeine metabolism: [Fast/Slow]

See Full Genetic Health Report: processed/[person]/genetic-reports/YYYY.MMDD.md

§18.05 Disease Risk Assessment from Genetics

High/Moderate Risk Conditions (Polygenic Risk Scores):

Condition	Genetic Risk	Population Comparison	Recommendation
[Type 2 Diabetes 2 型糖尿病]	🟠 Moderate	[1.3x average]	[Enhanced screening]
[Coronary Artery Disease 冠心病]	🔴 High	[1.8x average]	[Aggressive risk management

See genetic health report for complete risk assessment

§18.06 Carrier Status (Hereditary Conditions)

Condition	Gene	Carrier Status	Inheritance Pattern	Reproductive Implication
[Cystic Fibrosis 囊性纤维化]	[CFTR]	[Not a carrier ✅	[Autosomal Recessive]	[No concern]

Note: [X] hereditary conditions screened

§18.07 Genetic Counseling & Follow-Up

Date	Counselor Name	Topic Discussed	Recommendations	Next Steps
[Date]	[Name, CGC]	[FH risk / carrier status etc]	[Testing, screening etc]	[Action]

Title XIX: Wearable & Digital Health Data (可穿戴设备)

§19.01 Wearable Devices Used

Device	Type	Start Date	End Date	Data Collected	Sync Method	Notes
[Apple Watch]	[Smartwatch]	[Date]	[Ongoin]	[HR, steps, ECG, sleep]	[iCloud]	[Notes]
[Fitbit]	[Fitness tracker]	[Date]	[Date]	[Steps, HR, sleep]	[App]	[Notes]
[CGM]	[Glucose monitor]	[Date]	[Ongoin]	[Continuous glucose]	[App]	[Notes]
[Blood presure]	[BP monitor]	[Date]	[Ongoin]	[BP readings]	[App/Manua]	[Notes]

§19.02 Key Metrics from Wearables

Resting Heart Rate (RHR)

Period	Average RHR (bpm)	Trend	Notes
[MM/YYYY]	[XX]	[↑/→/↓]	[Notes]

Baseline RHR: [XX] bpm

Heart Rate Variability (HRV)

Period	Average HRV (ms)	Trend	Notes
[MM/YYYY]	[XX]	[↑/→/↓]	[Notes]

Baseline HRV: [XX] ms (higher is generally better for recovery/stress)

Daily Steps

Period	Average Steps/Day	Target	% of Target	Notes
[MM/YYYY]	[XXXX]	[10,000	[XX]%	[Notes]

Sleep Metrics

Period	Avg Total Sleep (hrs)	Avg Deep Sleep (hrs)	Avg REM (hrs)	Sleep Score	Notes
[MM/YYYY]	[X.X]	[X.X]	[X.X]	[XX/100]	[Notes]

Target: 7-9 hours/night

§19.03 Continuous Glucose Monitoring (if applicable)

Period	Avg Glucose (mmol/L)	Time in Range (%)	Time >10 mmol/L (%)	Time <3.9 mmol/L (%)	Notes
[MM/YYYY]	[X.X]	[XX]%	[XX]%	[XX]%	[Notes]

Target: >70% time in range (3.9-10 mmol/L), <25% time above range, <4% time below range

§19.04 Blood Pressure Monitoring (Home Readings)

Date	Time	Systolic	Diastolic	HR	Position	Notes
[Date]	[AM/PM	[XXX]	[XX]	[XX	[Seated]	[Notes]

Average (last 7 days): [XXX]/[XX] mmHg Average (last 30 days): [XXX]/[XX] mmHg

§19.05 Notable Alerts & Events

Date	Device	Alert Type	Value	Action Taken	Outcome
[Date]	[Watch/CGM]	[High HR / Low glucose	[Value/bpm	[Rested / ate carbs]	[OK]

Title XX: Mental Health & Cognition (心理健康)

§20.01 Mental Health Screening

Date	Screening Tool	Score	Interpretation	Follow-Up
[Date]	PHQ-9 (Depression)	[X / 27]	[Severity]	[Tx started / referred]
[Date]	GAD-7 (Anxiety)	[X / 21]	[Severity]	[Action]
[Date]	AUDIT-C (Alcohol)	[X / 12]	[Risk level]	[Counseling]
[Date]	MoCA (Cognition)	[XX / 30]	[Normal/MCI]	[Follow-up testing]

§20.02 Mental Health Diagnoses & Treatment

Diagnosis	Date Diagnosed	Severity	Current Status	Treatment	Provider
[Depression]	[Date]	[Mild/Mod/Sv]	[Remission/Active	[SSRI + therapy]	[Dr. Name]
[Anxiety]	[Date]	[Mild/Mod/Sv]	[Managed]	[CBT]	[Therapist
[ADHD]	[Date]	[Type]	[Controlled]	[Stimulant medication]	[Dr. Name]

§20.03 Cognitive Function

Date	Assessment	Score	Interpretation	Notes
[Date]	MoCA	[XX / 30]	[Normal/MCI]	[Notes]
[Date]	MMSE	[XX / 30]	[Normal/MCI]	[Notes]
[Date]	Executive function	[Qualitat	[Assessment]	[Notes]

§20.04 Therapy & Counseling

Start Date	End Date	Type of Therapy	Therapist	Frequency	Focus/Goals	Outcome
[Date]	[Date]	[CBT / DBT / IPT etc]	[Name, Ph]	[Weekly/etc.]	[Anxiety / Depression]	[Notes]

Title XXI: Treatment & Management Plan (治疗管理)

§21.01 Current Treatment Goals

Area	Current Status	Target	Timeline	Strategy	Status
LDL-C (血脂)	[X.XX mmol/L]	[<X.X mmol/L]	[X months]	[Statin, diet, exercise]	🔄
Blood Pressure	[XXX/XX mmHg]	[<130/80]	[Ongoing]	[Lifestyle / meds if needed]	✅
HbA1c	[X.X]%	[<5.7%]	[Ongoing]	[Diet, exercise, monitoring]	✅
Weight/BMI	[XX kg / BMI]	[Target kg / BMI 18.5-24.9]	[X months]	[Calorie deficit, exercise]	🔄
Exercise	[X min/week]	[≥150 min moderate intensity]	[Ongoing]	[Structured program]	🔄
Sleep	[X hrs/night]	[7-9 hrs]	[Ongoing]	[Sleep hygiene]	✅

Status: ✅ On target

🔄 In progress

⚠️ Needs attention

❌ Not started

§21.02 Upcoming Medical Appointments

Date	Provider	Specialty	Reason/Purpose	Location	Status
[YYYY-MM]	[Dr. Name]	[Cardiology]	[Follow-up, results review]	[Clinic]	[Scheduled]
[YYYY-MM]	[Dr. Name]	[PCP]	[Annual physical]	[Clinic]	[Scheduled]

§21.03 Monitoring Schedule

Test/Assessment	Frequency	Last Done	Next Due	Status	Notes
Lipid panel	[Every X months]	[Date]	[Date]	⏳	[Notes]
HbA1c	[Every X months]	[Date]	[Date]	✅	[Notes]
Blood pressure	[Every visit / weekly]	[Date]	[Date]	✅	[Notes]
Liver function (LFTs)	[Every X months]	[Date]	[Date]	⏳	[Notes]
Kidney function (eGFR)	[Annually]	[Date]	[Date]	✅	[Notes]
Eye exam	[Every X years]	[Date]	[Date]	⏳	[Notes]
Dental cleaning	[Every 6 months]	[Date]	[Date]	✅	[Notes]
Colonoscopy	[Every 10 years]	[Date]	[Date]	⏳	[Notes]

§21.04 Lifestyle Modification Plan

Dietary Goals:

☐ Follow Portfolio Diet / Mediterranean Diet / DASH diet
☐ Reduce saturated fat to <7% total calories
☐ Eliminate trans fats
☐ Increase soluble fiber to 10-25g/day
☐ Include plant sterols/stanols 2g/day
☐ Limit sodium to <2300mg/day
☐ [Other dietary goal]

Physical Activity Goals:

☐ ≥150 min/week moderate-intensity aerobic exercise
☐ 2+ days/week strength training
☐ Daily step goal: [10,000] steps
☐ [Other exercise goal]

Other Behavioral Goals:

☐ Achieve target sleep duration (7-9 hrs/night)
☐ Practice stress management techniques
☐ Limit alcohol to [X] drinks/week
☐ Maintain smoke-free status
☐ [Other goal]

Tracking Method: [App / wearable / journal / periodic check-ins]

§21.05 Barriers to Care & Action Plan

Barrier Identified	Impact on Health	Action Plan	Status
[Cost of medications]	[Moderate]	[Apply for patient assistance]	🔄
[Transportation to appointments]	[Moderate]	[Telemedicine / rideshare]	✅
[Difficulty adhering to diet]	[High]	[Referral to nutritionist]	⏳
[Work schedule conflicts]	[Low]	[Schedule early AM or late PM appts]	✅

§21.06 Shared Decision-Making Notes

Key Treatment Decisions Discussed:

Date	Decision Topic	Options Presented	Patient Preference	Rationale	Agreed Plan
[Date]	[Statin initiation]	[Lifestyle only vs Statin + lifestyle]	[Statin + life]	[High CV risk, CAC positive]	[Rosuvastatin 20mg]
[Date]	[Colonoscopy screening age]	[Age 45 vs 50]	[Age 45]	[Family history positive]	[Schedule at 45]

Title XXII: Clinical Assessment (临床评估)

§22.01 Risk Stratification

Cardiovascular Risk

10-Year ASCVD Risk: [XX]% (via ACC/AHA calculator) Risk Category: [Low (<5%) / Borderline (5-7.5%) / Intermediate (7.5-20%) / High (≥20%)] Lifetime Risk: [Elevated/Not elevated]

Risk Factors Present:

☐ Age: [XX] years [M ≥45, F ≥55]
☐ Sex: Male
☐ Hypertension
☐ Diabetes
☐ Dyslipidemia (LDL ≥[X], HDL <[X])
☐ Smoking
☐ Family history of premature CVD
☐ Elevated Lp(a)
☐ Chronic kidney disease
☐ Obesity (BMI ≥30)
☐ Physical inactivity
☐ [Other]

Risk Enhancers:

☐ Coronary artery calcium (CAC) score >0
☐ hs-CRP >2 mg/L
☐ Elevated Lp(a) ≥50 mg/dL
☐ ABI <0.9
☐ Metabolic syndrome
☐ [Other]

Diabetes Risk

Risk Assessment Tool: [ADA Risk Test / Prediabetes score] Risk Category: [Low / Moderate / High] Prediabetes Status: [Yes/No] (FBG 5.6-6.9 mmol/L or HbA1c 5.7-6.4%)

Cancer Screening Risk

Colorectal Cancer:

Risk: [Average / Elevated (FHx, IBD, polyps)]
Screening due: [Age 45-50 or earlier]

Prostate Cancer (Males):

Risk: [Average / Elevated (FHx, African American)]
PSA screening: [Discuss age 50 or earlier]

Lung Cancer (if applicable):

Smoking history: [Pack-years]
LDCT screening eligible: [Yes/No] (Age 50-80, ≥20 pack-years)

§22.02 Problem List (Active)

#	Problem	Date Identified	Severity	Status	Managed By
1	[Hyperlipidemia]	[Date]	[Severe]	[Active]	[Dr. Name]
2	[Coronary artery calcification]	[Date]	[Moderate]	[Active]	[Dr. Name]
3	[Obesity]	[Date]	[Mild]	[Active]	[PCP]
4	[Other problem]	[Date]	[Mild/Mod/Sv]	[Active]	[Provider]

§22.03 Problem List (Resolved)

#	Problem	Date Identified	Date Resolved	Resolution
1	[Acute illness]	[Date]	[Date]	[Resolved with treatment]
2	[Vitamin D def]	[Date]	[Date]	[Corrected with supplements]

§22.04 Clinical Summary

Patient Profile:

[Age]-year-old [sex] with [key medical history summary]

Major Health Issues:

[Primary diagnosis] - [Status, severity, management]
[Secondary diagnosis] - [Status, severity, management]

Overall Health Status: [Excellent / Good / Fair / Poor]

Functional Status: [Independent / Needs minimal assistance / Needs significant assistance]

Prognosis: [Excellent / Good / Guarded / Poor]

Key Management Priorities:

[Priority 1 - e.g., Aggressive CV risk reduction]
[Priority 2 - e.g., Diabetes prevention]
[Priority 3 - e.g., Weight management]

§22.05 Physician Assessment Notes

Space for physician to add clinical impressions, differential diagnoses, and longitudinal assessment

Date	Provider	Assessment & Plan
[Date]	[Dr. Name]	[S: Subjective / O: Objective / A: Assessment / P: Plan

Appendix A: Reference Ranges

Blood Chemistry Reference Ranges

Test	Reference Range	Unit	Notes
Glucose (Fasting)	3.9-6.1	mmol/L	<5.6 optimal
HbA1c	<5.7% normal, 5.7-6.4% prediabetes	%	≥6.5% diabetes
Total Cholesterol	<5.2	mmol/L	<200 mg/dL
LDL-C	<3.4 (optimal <2.6)	mmol/L	<100 mg/dL (optimal <70)
HDL-C	>1.0 (M), >1.3 (F)	mmol/L	>40 mg/dL (M), >50 (F)
Triglycerides	<1.7	mmol/L	<150 mg/dL
Creatinine	59-104 (M), 45-84 (F)	μmol/L	0.7-1.2 mg/dL (M)
eGFR	>90	mL/min/1.73m²	>60 acceptable
ALT	5-40	U/L
AST	8-40	U/L
TSH	0.27-4.20	mIU/L
Hemoglobin	130-175 (M), 120-160 (F)	g/L	13-17 g/dL (M)
WBC	3.5-9.5	×10⁹/L
Platelets	125-350	×10⁹/L

Conversion Factors

Cholesterol: mmol/L × 38.67 = mg/dL
Triglycerides: mmol/L × 88.57 = mg/dL
Glucose: mmol/L × 18.02 = mg/dL
Creatinine: μmol/L × 0.0113 = mg/dL
Urea: mmol/L × 6.006 = mg/dL (BUN)

Appendix B: Source Documents Index

Original Reports on File:

Date	Document Type	Source/Lab	File Location	Notes
[Date]	[Annual physical exam]	[Hospital]	raw/[person]/medical-reports/YYYY.MMDD.pdf	[Notes]
[Date]	[Cardiac CT]	[Hospital]	raw/[person]/imaging/YYYY.MMDD.pdf	[Notes]
[Date]	[Genetic test report]	[Lab]	raw/[person]/genetic-testing/YYYY.MMDD.txt	[Notes]
[Date]	[Consultation note]	[Clinic]	raw/[person]/clinical-notes/YYYY.MMDD.pdf	[Notes]

Processed Data Files:

Date	Document Type	File Location	Notes
[Date]	[Extracted medical report]	processed/[person]/medical-reports/YYYY.MMDD.md	[Notes]
[Date]	[Genetic health report]	processed/[person]/genetic-reports/YYYY.MMDD.md	[Notes]

Appendix C: Data Visualization Guide

Tracking Key Metrics Over Time:

LDL-C Trend (Example)

LDL-C (mmol/L):
6.0 ┤                                        ×
5.5 ┤                    ×       ×
5.0 ┤        ×
4.5 ┤
4.0 ┤
3.4 ┤────────────────────────────────────────  Target
3.0 ┤
2.0 ┤
    └┬────┬────┬────┬────┬────┬────┬────┬────→
    2018  2019  2020  2021  2022  2023  2024  2025

Action: [Statin initiated 2025-09]
Target: <1.8 mmol/L (high-risk) or <1.4 mmol/L (very high-risk)

Suggested Visualizations:

Lipid trends (LDL, HDL, TG) - line graph
Weight / BMI trend - line graph
Blood pressure trend - scatter plot with trend line
HbA1c trend (if applicable) - line graph
Medication adherence - calendar heatmap

Tools:

Spreadsheet software (Excel, Google Sheets)
Health apps with data export
Custom visualization scripts

Appendix D: Usage Instructions

How to Use This Personal Health Code (PHC)

For Patients:

Initial Setup:
- Fill in all known baseline data (demographics, medical history, current medications)
- Gather all available medical records and enter historical data
Regular Updates:
- After each medical appointment, add new lab results, vital signs, diagnoses
- Update medication list when prescriptions change
- Record new imaging studies, procedures, vaccinations
- Update Quick Reference Dashboard with critical status changes
Before Medical Appointments:
- Review your PHC document
- Note any questions or concerns to discuss
- Bring printed copy or share digital file with provider
For Emergency Situations:
- Quick Reference Dashboard provides critical info at a glance
- Medication list (§ 13.01) and Allergies (§ 13.04) are immediately accessible

For Healthcare Providers:

Initial Review:
- Start with Quick Reference Dashboard for critical status
- Review Problem List (§ 22.02) for active issues
- Check medication list (§ 13.01) for current therapies
Focused Assessment:
- Navigate to relevant Title for specific organ system
- Review historical trends (tables show chronological data)
- Check genetic data (Title XVIII) for pharmacogenomic implications
Treatment Planning:
- Review Treatment Goals (§ 21.01)
- Check monitoring schedule (§ 21.03)
- Update clinical assessment (Title XXII)

Document Maintenance:

Update Amendment History (Title XI) with each significant revision
Archive old versions before making major structural changes
Back up regularly - store encrypted copies in multiple locations
Review annually - ensure all sections are current and accurate

END OF PERSONAL HEALTH CODE TEMPLATE v2.0

This is a living document template designed for comprehensive health data consolidation.

All sections marked with [brackets] require patient-specific data entry
Maintain original lab/imaging reports as source documents (Appendix B)
Update version number with each significant revision
Share with healthcare providers as a comprehensive medical summary
Based on the proven structure from yunjie.md with 22 Titles covering all aspects of health

Template Change Log:

Version	Date	Changes Made	Updated By
2.0	2025-10-10	Complete restructure based on yunjie.md (22 Titles	AI
1.0	2025-10-08	Initial template (12 Titles)	AI

phc