Medical History Example

The following topics are just suggestions.  Skip ones that don't apply and add others that you need for your particular circumstances.  If you have a word processing program that allows it, use tables, bold, and even red text to make headings stand out.

Following the examples are instructions for each section.

 

OPENING -

* Name and age  (Add any important notations, like blind or deaf, in large font)

* Name of a person to contact in emergency with phone numbers.

* If you have a living will or directive to physicians, note it here and who has a copy of it.  Sometimes a doctor or hospital will ask for a copy to be kept on file.  In the March 1 post, " Before Your Parents Need Help," I talked about wills, durable power of attorney. medical power of attorney and living wills.

CAUTION:  The government HIPAA laws have changed regarding patient privacy issues.  That, along with the risks of identify theft, mean you should leave out specific information including social security number, birth date, and insurance numbers.  You can give this information directly to the doctor or hospital when needed.

ALLERGIES -

Be sure this stands out well.  Use red and bold text. 

* List major allergies, like medications, bee stings, fish or peanuts.  Where possible, list the reaction to the item. 

* List contact allergies, like latex (so a doctor will know not to use latex gloves) or ingredients in lotions or creams.  Also, add any inhaled or food allergens, like grasses, trees, or wheat.

SHOTS -

List the latest shots you've had with the date, especially flu and pneumonia shots, last tetanus shot, and other important shots, like the shingles vaccine.

DOCTORS -

List your main doctors with phone and fax numbers.  Putting these numbers in your history means you'll have the contact information if anyone needed it. 

If you have moved within the past year, you may want to include the names, addresses, phone and fax numbers of your previous doctors.

MEDICATIONS -

List your medications with the dosage and number of times you take it each day.  Include any PRN (as needed) medications you have on hand at home, any over-the-counter (OTC) medicines you take regularly, vitamins and supplements, and any herbals or homeopathic medications.  (This will help your doctor in making sure you have no problem with drug interactions.  See my post on Drug Interactions for more details.)  Leave space to add new prescriptions as you get them.

CURRENT PROBLEMS -

If you are seeing a doctor for an ongoing problem, or as a follow-up to a hospital stay, you may want to include an overview of the situation.  For example, the date of a broken ankle, the date the cast was removed, and the dates for physical therapy.

CONTINUING MEDICAL CONDITIONS -

In this section, list all existing conditions such as high blood pressure, diabetes, high cholesterol, or osteoarthritis.  Include dates when applicable, like diabetes type 2 since 1995.  Also list conditions such as pacemakers, insulin pumps. or cataract implants.

SURGERIES -

Most doctors want to know what previous surgeries or hospitalizations you've had so they can see patterns that might help diagnose your health problems or let them know what your physical limitations might be.  List important problems as well as accidents, childbirth, and childhood issues such as having tonsils or appendix removed.  Add the year if you know it.

PREVIOUS HEALTH ISSUES -

These are the diseases and conditions usually listed on a doctor's form that you are supposed to check off.  In this case, just list the ones that apply to you.  Add the year or your age at the time, if applicable.   

The list below contains many of the common conditions doctors ask about, so pick any that apply and add any specific issues not listed here that you think the doctor should know about you,

If it may be important to your health, be sure to add an additional list of conditions in your family history that apply to you.  These would be inherited type problems like diabetes, cancer, high blood pressure, hypertension, stroke, and heart problems.

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Medical Conditions

ILLNESSES - Measles, German measles, mumps, chicken pox, mononucleosis, polio, diphtheria, malaria, rheumatic fever, scarlet fever, venereal disease, yellow jaundice, thyroid disease, renal or liver disease, bronchitis.

CONDITIONS - Diabetes, asthma, emphysema, stroke/TIAs, seizures, arrhythmia, history of aneurysms or blood clots, epilepsy, ulcers, arthritis, cancer, diverticulitis, hepatitis, eye problems, headaches, nose bleeds, sinusitis, shortness of breath, chronic cough, smoking, drinking, drugs, bowel problems (chronic constipation or diarrhea), colitis, male or female specific problems, gout.