How Do I Record My Medical History?

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Since I am back to searching for a new primary doctor, I am revisiting these steps. I need to update all of my medical records. I thought I’d share my outline with you. I hope it is helpful.

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You are responsible for your medical history. I always carry a list with me. When I get to an appointment, my memory ceases to be present! This list ensures any information requested of me is available.

What to Include:

• Name and Personal Information
• Medical Providers
• Medical Conditions
• Illnesses and Surgeries
• In Patient Hospital Stays
• Emergency Room Visits 
• Medications
• Allergies
• Medication History  

There may be a more appealing way to do this, but at least this is a quick way to organize medical notes to bring with you to every medical appointment you have, including dental appointments!

So let’s go over what is most important for you to carry with you, in your purse or on your person at all times. Then you decide if you want to put this information on your phone, in a computer file you can print out and carry with you or merely handwrite this information out. Whatever works best for you!

Your Name and Personal Information. Date of birth and street address, with a phone number and emergency contact. Simple!

Medical Providers; their business addresses and phone numbers. Do this for EVERY physician, specialist, therapist, and dentist you currently see. Get that information down.

Medical Conditions you have been diagnosed with! List them.

Illnesses and Surgeries. Do a timeline for illnesses and surgeries. Just get the month and the year down for the medical event.

In-Patient hospital stays. Remember as best you can the tests and procedures you had done and include them.

Emergency Room Visits. Listing E.R. visits are optional if you follow up immediately with your doctor. The testing completed during the visit should be noted.

Medications. List your current medications, supplements, and PRN (as needed) medications.

Allergies. List them.

Medication History. Try to remember medications you have taken, the medication dosages, the effect this medication had on you and why it was discontinued.

Much of this information you can request from medical records and your pharmacy. Just give them a call. I have found the medical records personnel to be very helpful in sending me what I need. One exception, they do not go back farther than seven years. Just like taxes, medical records older than seven years are destroyed, so, get working on this!

Just follow this outline and remember to carry this with you at all times! This is part of excelling at being a responsible patient. And it is worth every minute you work on this because when the nurse or doctor asks you a question all you need to do is hand them your list.

Make copies so they can keep the list you hand them.

Take charge of your health and live your best life!

~Kim