Abstract\r\nBackground\r\nPersonal Health Record includes a wide range of data. This use of the data set is important. There are valid datasets for an integrated health care delivery is essential. People with disability make up a whole strata of society in the Iran that due to lack of their awareness of in enough attention to formation of PHR as self-care and following of their health process, researcher\'s aim was to determine dataset PHR for people with disability.\r\nMethods\r\nThis is a combination of 3-stage study: 1. In order to designing data set of PHR designed for people with disability with views of experts in specialized fields (medical, paramedical, nursing, and rehabilitation) items. 2. Its content validity has been approved by 4 experts and its reliability was confirmed with Cronbach\'s alpha value of 0.97. 3. The Delphi method was used. After the approval by consensus survey with Likert scale score higher than 4, proposed form designed.\r\n\r\nResults\r\nForm proposed was designed by agreement 96 % in 8 main sections including demographic data, history, information, physiological, clinical data, rehabilitation information, lifestyle, lab results and treatment, 73 % agreed with the 35 data, and 83% agreed with the 80 sub-categories. \r\n\r\nConclusions\r\nReaction people with disability were positive to form in research process as well as they demanded form for self-care and next referrals to health centers. Now the proposed form are distributed between patients who are disabled by the health centers in the province.\r\n