How to use the page called " Medical History" - a Medical History Summary form
* Never omit or falsify any information in your medical histories! Your life may depend on it
Medical schools teach that the most important step of making an accurate medical diagnosis is not physical examination or fancy medical tests and equipment. The doctor is best served by taking a proper medical history.
Surprisingly, most people do not know many of the details of their own health. This is a frustration to all health professionals, and contributes to misdiagnosis and even medical errors.
Technology will eventually catch up with our need to have timely access to medical information. In the meantime, follow the suggestions here to create a quick record of your past medical history.
(1) Keep your medical history summary up-to-date no matter what method you use.
(2) Print out copies to take each time to your doctor's appointments.
(3) Clearly mark major changes that have occurred since you last saw that doctor.
(4) Carry your most recent summary with you at all times.
You may want to track your history by creating a new page whenever a major piece of information needs editing. For instance, you might want to use a system which incorporates the date - such as "My Medical History, 17 Apr 2007"; "My Medical History, 28 May 2007"; "My Medical History, 17 Jul 2007"; etc.
How to begin:
Request copies of your full medical record from your primary care physician.
If his or her office is using a modern computerized charting system, or if the doctor has been particularly diligent with their paper chart, a "Front Sheet" or "Cumulative Patient Profile" may already be available to print or photocopy.
Explain that you are trying to maintain a personal health record. Once you have a copy or summary (yours or your physician's), use the information in it to help record the main information for a summary. Steps to create that summary are found on this page (below).
Note: You will likely have to pay a copying charge for your initial records file. This is usually on a per-page basis - currently about 25¢ a copy. Afterwards, any requests you make for copies of test requests, test results, consultation/authorizations, and so forth, to update your own files - if made at your provider's office during the time of service - will usually be provided free of charge.
You may want to mention at appoinment check-in that you will be asking for copies as you check out. Remember to be courteous to the administrative staff ; - ) At home, be sure to summarize your doctor's visit for your own records as soon as possible; the memory is a fragile thing.
STEP 1. Obtain copies of your medical record as described just above and use its information to complete the summary page.
All the steps that follow are annotated, and they all are included on the web page on this site called "Medical History."
That summary form itself is pretty self-explanatory, but I have included the steps with annotations to explain what you'll be doing.
NOTE: Right now, you may only want to skim the information in Steps 1 to 6. Once you've completed the form for the first time, you might want to review those steps and continue reading and acting from Step 7:
STEP 2. Write down basic information about yourself: your insurance; doctors; etc.
Include the following:
Item 1. Basic information: Full name (with surname in all caps):
Health insurance information:
(a) Provider:
(b) Group number:
(c) Policy number:
(d) Name of policy holder:
(e)Your relationship to policy holder:
Date of birth:
Sex:
Next of kin and/or power of attorney for health care (relationships noted):
Addresses and phone numbers (yours and that of next of kin):
Your full mailing address:
Phone(s):
Next of kin full mailing address and phone contact numbers: (x)
Same as above (i.e. same as mine) (x)
Other: Primary Care Physician and contact information:
Pharmacy name and phone number:
STEP 3. List your past medical history:
Item 2. Past Medical History summary:
Medical diagnoses/conditions (all known major diagnoses):
Past surgical history with dates, locations (includes reason for surgery and outcomes):
Allergies (especially medications) and the way you have reacted to them in the past:
Names and specialties of physicians who are still following you (includes addresses and contact information):
STEP 4. Include a complete list of the medications you are taking:
Item 3. Current medications:
Prescription medications (dose and number of times per day taken):
Specialized treatments (includes chemotherapy, drug trials, medication injections):
Over-the-counter remedies ( e.g. Tylenol, Gravol, etc):
Herbal medications, vitamins and supplements:
Cigarettes per day: Alcohol consumption per day (average):
Street drugs (e.g. marijuana, cocaine, etc.):
STEP 5. Summarize the results of any medical tests you have access to (don't bother bringing any actual pictures unless seeing a specialist in that field):
Item 4. Medical tests summarized:
Most recent bloodwork (date and summary of findings):
Summary from currently relevant written report(s) of xrays, MRIs, CTs, etc:
Photocopy of recent electrocardiogram (ECG) attached? [Cirlce the relevant answer] (x) NO (x) YES
STEP 6. Consider writing advanced care directives - especially if you are elderly; have ever had any life-threatening conditions; or have specific care requests.
Item 5. Advanced care directives (All relevant directives are circled [x] and initialed):
(x) All medical measures may be taken - including life support if I am unable to say otherwise
(x) Organ donation authorized
(x) No CPR, no Ventilation, no Life Support
(x) No blood transfusions (x) DNR - "Do Not Resuscitate"
Signature: _________________________
Date: ____________________________
STEP 7. Type out all the information on one side of one sheet of paper. (Print as needed. )
Sign and date the sheet.
Keep this emergency information with you at all
times.
__________________________________
Warnings:
* Worth repeating:
Never omit or falsify any information in your medcial histories! Your life may depend on it, particularly if you go to the hospital in a critical state and cannot speak for yourself.
* Do not assume that technology will make your medical information readily available and that a summary is unnecessary.
As a whole, patients with chronic pain experience complicated treatments and see a number of doctors. Do not assume that all your medical information is available on some computer or that it is shared between all relevant parties. More often than not, this is not the case.
Even in a modern emergency room, where the most critical care is done, many patients are treated with no access to any previous health records.
*Your summary sheet serves the same purpose as a cover letter in a job interview, so try to keep it to one printed page.
That will help ensure that it is read and digested - that physicians won't assume that reading it will waste their time. If it takes longer to read your summary than it would to go hunting for the information in other ways, the doctor may not bother to read it at all.
Tips:
* Carry a copy of your summary with you everywhere, in the same place you keep your health card.
* Update it whenever significant changes occur (or, if you've used a printout of your medical summary from your family doctor's office, just get your doctor to print out a new one). When seeing a new doctor or specialist, ask them to edit the sheet to reflect the changes they want.
* If you are on many prescription medications, your pharmacy can probably print you out a summary of those. * Whenever registering for an appointment or visiting the emergency room, show the sheet to the first nurse or clerk who assesses you and ask that it be shown to the doctor. Also, be sure to show the sheet to an EMT or Paramedic should an ambulance be called for you.
* Consider emailing a copy of the Cumulative Patient Profile (CPP) to yourself and to anyone who plays a role in your care (family or a Power of Attorney). That way, it is always available online even if it gets forgotten at home.
Source: This file and the medical history summary page rely on "How to Summarize Your Own Medical History" an online article in wikiHow, an online contributor-written encyclopedia
