Each new medical provider asks the same pesky health questions you’ve been asked time and time again. Documenting your medical history in a readily available format saves time and frustration with each new request.
Think about the number of times you’ve had to answer that same long list of health questions at a doctor’s office or during a trip to the ER. This process can be so tedious and frustrating! And it becomes even more difficult if you accompany a loved one to an appointment and you have to answer for them. In this highly electronic world, you’d think that all this information would be readily available to any medical provider at the click of a mouse, but unfortunately, you can’t count on that.
Accurate answers to the pesky questions can be essential for assuring you get the right medical care. From medications to family history, these details can impact your diagnosis and treatment. By documenting your medical history in an organized, readily available format, the task of recalling the important minutiae becomes so much easier, and you’ll be less likely to forget important details.
Recording everything from health conditions and surgeries to prescriptions and vaccines (and everything in between!) may feel a bit overwhelming. Below we break this project into manageable steps, so you can create your personal health record, a comprehensive picture of your health journey that can help optimize your care.
Information for documenting your medical history
General info
In this first section, include a list of the basics:
- Your full name, date of birth, and blood type
- Doctors, their specialties, and contact info
- Insurance information
- Emergency contacts
Medications, vaccines, and allergies
Since medications have side effects, medication errors can occur, and drug and supplement interactions may have negative ramifications, it’s essential that health care professionals know your regimen of medications and supplements. List:
- Current medications, along with their dosage
- Current supplements and dosage
- Allergies to medications, foods, etc., including your reaction
- Vaccines, such as flu, Covid, and RSV. Ideally, include your last tetanus shot and childhood vaccines (this is a good reminder to pass along vaccine records to your grown children!)
Medical conditions and treatments
Knowing what health challenges you’ve had helps the health care professional consider successful treatments for other conditions. List:
- Current and past conditions and approximate diagnosis dates
- Surgeries or other procedures: include the treating physicians, dates, and outcome.
- Test results: bloodwork, EKGs, colonoscopies, mammograms, etc.
- Women: include reproductive health history including pregnancies, childbirth experiences, and menopause onset
Family health
Genetics can play a role in some medical conditions, such a heart disease, diabetes, dementia, and cancer. When medical professionals know your risk, they can provide you with the appropriate testing and care that may prevent you from developing these conditions or minimize the risk. List:
- Each family member (parents and siblings, plus blood relatives once removed, such as aunts and grandparents)
Other health information
Lifestyle factors may affect treatments as well as outcomes. List:
- Smoking, alcohol use, and recreational drug use, including cannabis (past and present)
- Exercise: type, frequency, and intensity
- Any history of depression or other mental health problems along with the treatments
For an even more in-depth history, include copies of medical records. Johns Hopkins also recommends including hospital discharge summaries. Just in case, consider including copies of legal documents such as your advance directive (living will) and power of attorney.
For all of this information, be sure to keep the information current as your health changes.
How to store this important information
In documenting your medical history, you can always organize paper records in a binder or file, but be sure to store these records somewhere secure like a fireproof safe. Share the lock combination or the location of the key to your safe to someone who might accompany you to your health care appointments or has medical power of attorney.
Transfer the most important information to a digital file so you’ll have it whenever you need it. Use the note apps or document storage on your smartphone to ensure easy access. Consider medical record apps like OneRecord or MyDigiRecords and cloud services such as Google Drive and Dropbox where stored documents can be accessed from anywhere. If you go the digital route, keep a paper backup and share the log-in information with someone.
These days, patients see so many medical providers spread across so many health systems. We all need to be fully informed about our own health and active in coordinating care. Documenting your medical history and having it at the ready is the first step toward achieving this goal.
