Open Wide and Say: “Here is My Medical History!”

It is essential to know the major details of your own medical history. The more accurate the information you give your doctor the better the diagnosis and care.

This is Not Too Complicated

Drug allergies and sensitivities are only the beginning; any treatment therapies that you have tried and their effect on you-good or bad are also important to note.

Compiling a Medical History does not have to be complicated. Some people have a very limited medical history and it is easy for them to remember hospitalizations and other major illnesses. But for those who suffer from chronic illnesses it is essential that a written record is compiled and kept with them at all times. A Medical Journal can be useful in compiling some of this information.

Your notations in your Medical History need not be lengthy. There are some basics that should be included on one page: Any medical conditions you currently have.

1) Your current medications with the dose and frequency noted, along with the corresponding medical condition.

Example- Bextra 20 mg –once a day- (arthritis)

2) Include the full name, address and phone number of your primary care physician and any specialists you see.

Keep this page in your purse or wallet. It is a good idea to let your family and friends know where you keep your information. Emergency medical personnel will find this very useful in the event you are unable to speak to them.

What Happened and When

On subsequent pages include:

1) Any past medical conditions

2) All major operations with approximate dates and places they were performed.

3) Any major traumas you have experienced, i.e., auto accidents, etc.

4) Family History of medical problems.

5) Women should include a thorough gynecological history. This should include, among other things, the number of pregnancies and births, along with any complications.

When on vacation or anytime you are far away from home be sure to keep a full copy of your medical history and latest test results with you. Sometimes it is hard for the attending physician to get in touch with your primary care physician. Having a copy of your latest test results and your history will help them determine your baseline readings.

A Little Every Day

A Medical Journal will help you to organize this information, as well as, keep track of the daily changes in symptoms and medications. An inexpensive bound journal and pocket folder can be purchased at a local discount store. In less than 5 minutes a day you can keep an accurate record of any changes in your condition. Here is an example of how to start your journal:

On the right page list the daily notations such as:

1) Daily weight

2) Heart rate, blood pressure, blood sugar, etc.

3) Changes in medications

4) Current symptoms

On the left page list:

1) Questions for the health care provider.

2) Any medications you discontinued, along with when and why.

3) Prescriptions needed to be refilled.

4) Instructions from the health care provider.

In the pocket folder:

1) Copies of lab work results.

2) Names, addresses, and phone numbers of Support Groups.

There may be a fee for copies of your lab work, but they may be useful if you are away from home, and need medical care. The attending physician may have difficulty reaching your regular health care provider, and having your baseline readings may prove helpful.

The important thing to remember is you can have an active role in your health care. You do not need a degree to be informed about your health.

© Copyright 2003 Catholic Exchange

Deborah A. Lonergan is a free-lance writer from Pennsylvania. She lives in a small town with her husband and three sons and writes a column for a local newspaper entitled “Take Charge of Your Health”. Her goal is to demystify medical care and let people know it is essential that they become their own best advocate. She worked as a medical office administrator for several years and she is personally aware of the need to be an informed patient.

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