It's SAFE to Ask
Patient Engagement Resources About Home Make it Safe S.A.F.E. Toolkit

Resource materials featured on this page

have been developed by the

Manitoba Institute for Patient Safety.

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My Health Plan

One of the best ways for the public to promote patient safety is to be involved in their healthcare. A new MIPS resource, that complements our It’s Safe to Ask family of resources, helps people do this. My Health Plan includes templates and resources for the public to create their own health plan, such as recording family history, emotional and mental health, health habits, appointments, referrals and consultations. Health plans can be kept electronically or printed and stored in a binder. We included sections to keep copies of our It’s Safe to Ask brochure and Medication Card. My Health Plan helps people keep up to date and up to speed on their healthcare journey.

A health plan is a record of your past, current and future healthcare information and goals. You can include anything you want to in the plan. Here are templates and resources for you to create your health plan:

Family History

Surgeries and Hospital Admissions

Illnesses and Injuries

Emotional and Mental Health

Health Habits

Referrals and Consultations

Appointment Log


It’s Safe to Ask Medication Card – use to keep track of medications

It’s Safe to Ask Brochure – use to record answers to 3 key questions

Here are cover pages for documents you print or download:

Test Results and Consultation Reports

Test Requisitions

It’s Safe to Ask Medication Card

It’s Safe to Ask brochure

You can also contact the Manitoba Institute for Patient Safety at 204-927-6477 or for a free copy of any of these resources. Find the entire set of templates in one package here, called My Health Plan.

With these templates, you can:

1. Print them, fill in the information, hole punch, and keep them in a binder.

2. Use the fillable pdf version and keep an electronic copy on your mobile device or computer. Be sure to save template first before filling in your information.

If you keep an electronic copy, be sure to scan and save your test results and consultation documents so that all documents are in the same place and easy to find.


Manitoba Institute for Patient Safety

102-175 Carlton Street

Winnipeg, Manitoba R3C 3H9


t: 204.927.6477x  f:x204.779.6477

Toll Free: 1.866.927.6477x