How To Write A Personal Medical History Form

How to make you own personal medical history form that can be kept at home as an important health reference and shared with pertinent health care practitioners.

In this day and age of managed health care and a more educated health consumer, it is important to keep an accurate and current medical history on yourself and loved ones.

The first step in recording a personal medical record is to collect any and all information that pertains to your health care, including records of visits to the doctor's office, documents of trips to the hospital or ER, and any medical bill and papers related to your insurance plan, and etc.

Step one also includes going to anyone who has participated in your health care throughout your life (parents, schools, primary care doctors, specialists, counselors, and others that come to mind), obtaining as much information as possible.

You will soon find out that some data is lost forever, impossible to uncover, or too difficult to retrieve, and that is okay if the information is not critical or too important.

Depending on how extensive your health history is, I would not spend more than a total of 5-10 hours to implement this initial phase of information gathering.

Invest an hour or two a day spread over a few days to collect the basic, yet important facts. You can always add details and new data as time goes on and as you get more proficient at recording your medical history (especially, as it occurs).

Concentrate on dates, health visits, sicknesses, treatments, immunizations, childhood illnesses, medications (spelling, doses, what it was for, etc.), doctors' names, and other facts that would be important to health care practitioners you may see in the future.

Keep in mind the who, what, where, when, and why rules of information gathering. Make phonecalls, use the fax machine, and do anything else that can make the data collection process efficient and save you from unnecessary trips and wasted time.

Step two involves writing a time line of your health history, including specific illnesses, hospitalizations, surgeries, significant physician contacts, loss of work, injuries and accidents, medication use, and other elements that will be discussed in step three.

Start this time line by recording the major events that you can recall by memory, then begin to fill in the details offered by your personal data search. This whole process will spur your mind to remember even more medical events and facts that may have long been forgotten.

Step three is to organize all of this information into a form with which doctors and medical practitioners are most familiar. You can never be too accurate or detailed in your documentation, and a good practitioner will always appreciate your initiative to assume more responsibility for your body, mind, and health.

Physicians, physician assistants, nurses, and nurse practitioners like to record their patients' medical histories in a certain fashion, and a copy of this document that you create about yourself or a loved one should be kept in a paper file at home and on a computer disc if possible.

Take a copy of this personal medical history with you when you visit a health facility, and share it with practitioners whom you choose. You may also want to store a copy at a relative's home or in a safe deposit box just in case something unfortunate happens to your abode.

These are the following elements that ought to be recorded in your final personal medical history:

1) Name, gender, birthdate, marital status, religion

2) Spouse name, emergency contact person, health proxy, childrens' names and birthdates

3) Address, home phone, work phone, Email, fax

4) Insurance company and number

5) Names and phone numbers of significant and recent practitioners seen - primary care doctor, specialists, chiropractor, pharmacist

6) Present Medical Conditions - for example, diabetes, high blood pressure, hayfever, and other conditions that are current or chronic in nature; diseases and illnesses that affect your body often or always

7) Current Medications - correct names, doses, when taken, when began, who prescribed, side effects, over-the-counter products, vitamins, herbs, and etc.



8) Allergies - to medicines, foods, chemicals, natural and man-made substances, insects, and anything that causes an unusual reaction to your body; note how you respond to it

9) Past Medical History - childhood illnesses, immunization history, pregnancies, significant, short term illnesses, longer term conditions,and other diseases that affected you in the past and are not mentioned in Present Medical Conditions

10) Hospitalizations - include in-patient stays, ER visits

11) Surgeries - minor and major, with anesthesia, out-patient, deliveries, invasive procedures, etc.

12) Significant and recent Blood Tests - most doctors will give you a copy of any bloodwork that is done on you; record only the significant values in this document and file lab records; some of the imoportant numbers include glucose(sugar), fasting cholesterol, white blood cell count, cancer values, kidney function, and several others that your doctor should tell you about (so have your practitioner help you with this section to be more accurate)

13) Special tests and Procedures - Examples include Xrays and other radiology tests, EKG, stress test, echocardiogram, colonoscopy, and other similiar procedures done at a health facility

14) Family History - limit it to the significant diseases of your grandparents, parents, siblings, and children

15) Injuries, Accidents, Disabilities - what happened and was done for it; how it has and does affect you now

16) Review of Systems - this is a catch-all section for any other problem you may be having or have had in the fairly recent past. Under each of the following body systems, note any problems, symptoms and signs you experience, recent sicknesses, and other aspects that may be related to that particular part of the body:

a. Neurological - brain, nerves, headache, etc.

b. Eyes - wear glasses?, vision test results

c. Ears - hearing, infections

d. Nose, Sinus

e. Throat

f. Neck

g. Lungs (Respiratory)

h. Heart (Cardiac and Vascular)

i. Gastrointestinal - particularly esophagus, stomach, intestines, rectum, liver, gallbladder, pancreas

j. Urinary - kidneys, bladder, etc.

k. Sexual Organs - STDs, recent activity and problems, drive

l. Musculoskeletal - spine, bones, joints, muscles

m. Endocrine - glands, hormones, thyroid, diabetic symptoms, and related functions

n. Blood and Lymph Systems - anemia, iron deficiency

o. Psychological - depression, anxiety, adverse attitudes, mood swings, and mental problems

p. General - fatigue, weakness, memory loss, confusion, weight changes, appetite, pain

17) Social History and Lifestyle - Habits, diet, exercise, sports, hobbies, household situation, frequent activities, significant relationships

18) Work History - current jobs, recent jobs and significant, past occupations; particularly if you endured special work hazards, risks, stress, and other factors that have affected your health

19) A Chronological List of significant Practioner Office Visits in the past year or two

Recording a medical history in this manner will greatly help you in understanding and gaining control of your health. It will also help your present and future practitioners treat you much more effectively.

If done with persistence and patience, keeping a personal health history and taking a copy of it with you when you visit a doctor or other health practitioner, over time, will enable you to become more familiar with your body's conditions and help you to take care of yourself better.

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