How to Make a Personal Medical History Form

You want to keep a copy of your medical history so that health care practitioners can better assist you. Make a copy of this information for your children in case you are incapacitated or to help them with their own medical issues. Use these tips to make a personal medical history form.

Instructions

1. Create a chart with all your personal information. Include your name, address, phone number, birth date, spouse, children and insurance information. Add your blood type, immunizations, tests, results and surgery.

2. Include all your allergies including details of what you are allergic to, what happens when you are exposed to the allergen and how you are treated for the allergy.

3. Make a table for all your medication. List the medication's name, side effects, duration of use and the reason you were on it.

4. Visit your doctor and ask for copies of any medical forms in your file. Include the medical information on your personal chart. Attach the doctor's papers to the medical history form.

5. List any of your hospital visits on the form. Include tests, results, surgeries and visits to the hospital or emergency room. Add names of doctors and specialists if you remember them.

6. Ask your parents and siblings to list any illnesses you had as a child. Use your memory to fill in any gaps. Include any current medical concerns you have presently and any relevant family history. Create a timeline with all your information. Leave space for additional information.

7. Download a medical history form from the Internet (see Resourced below) and fill in the blanks with your own information.

Tips & Warnings

• Save your personal medical history form on a computer and back it up on a disk.

• Add your medical bills and insurance claims to your health care file.

• You may have to pay for copies of your medical file.

Resources

• You can use this personal medical history form.
• Use this sample form to create a medical history form.