How to Write a Personal Medical History
Personal medical histories are summary documents that outline an individual's heath history. They help new physicians, consulting specialists and emergency surgeons make the best possible decisions about care. The histories may also be important to close family members and descendants who experience medical issues of their own. Individuals should keep an updated personal medical history in a safe, accessible place and should provide an annual copy of the history to their primary care physicians and to specialists that they visit regularly such as gynecologists or allergists.
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Instructions
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List your personal information. State your full legal name, any nicknames or aliases by which you are known and your date of birth. Give your mailing address, phone number and any other contact information. Provide the name and number of the person to be called in an emergency. If possible, provide a secondary contact who can be called if the first person in unavailable. Date the history so the reader knows how current your information is. If you know your blood type, list it.
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List your allergies. Include all known drug allergies, food allergies and other allergies (such as latex.) If you do not have allergies, do not omit this section. Instead, write: "Allergies -- NKA" (meaning "no known allergies") or "Allergies: none." This lets the reader know that you did not forget about allergies but, rather, you do not have any.
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List all medications you are currently taking. Include prescription and over the counter drugs. Include the amount of each dose, the form that you take (oral capsule, oral liquid, injection, etc) and the frequency with which you take the medication (once daily, every two weeks, etc.) Remember to include treatments such as allergy desensitization shots, supplements such as vitamins and prescription medications used as needed such as an asthma inhaler.
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List all incurable or recurring diseases or conditions that you may have. This alerts medical providers to consider possible underlying causes and potential side effects when determining your treatment. It also provides critical safety information in the case of communicable diseases. List the name of the condition, the date of onset, your current course of treatment and the name and phone number of the physician responsible for your treatment.
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List all past surgeries, major accidents and serious illnesses with the most recent first. List the diagnoses, the procedure, the date of occurrence and the supervising physician. List any ongoing or permanent effects. If anything was removed (such as your gallbladder) or inserted (such as a permanent steel pin), say so. Include common childhood diseases such as measles and indicate all pregnancies. You need not include common illnesses such as colds or minor sinus infections unless they are a result of another condition or occur excessively.
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List all immunizations including the type and date. Include the date of your last tetanus shot.
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List all family histories of major diseases and conditions. Give the disease or condition and list the affected individuals. Include information only for blood relatives. If you do not know some or all of your family history, you may wish to state this.
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List your primary care provider (your regular doctor.) Include her full name, the name of her practice, the practice address and phone number. If you are under the regular care of any specialist, list his information as well. You may also state that the reader has permission to request information from or discuss your care with your primary care physician or other doctor. Sign all such statements.
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Tips & Warnings
Tell your next of kin or a responsible friend where to find your personal medical history so they can get it to your doctor in case of an emergency. The more information the doctor has, the better your treatment will be.
References
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