How to Write a Health History

How to Write a Health History

Dealing with healthcare today can be stressful. Memories get mixed up in times of stress. Accordingly, keeping a personal health history is one of the most important steps people can take to improve the safety and quality of the health care they receive. It is vital that you are a partner with your healthcare providers. A personal medical record can be a real lifesaver. Learn to be your best advocate by being prepared, in advance with a written health history. Taking the time to document and prepare a truthful and accurate healthcare history can make a life- saving difference with the treatment you receive. Most important is to Be Honest.

A detailed health history should include:

• A specific family health history, parents and siblings’ major diseases and age and cause of death.
• Individual contact information for each of your physician practices including your primary care, as well as any adjunct services: orthopedic, cardiac, or neurology.
• Each section should include test results that have been done in the past including any lab results, EKG, scans, MRI’s. Keeping in chronological order, most recent on top.
• Highlight past complications to surgeries, specifically any anesthesia difficulties.
• Document activities you are currently doing to focus on a healthy lifestyle.
• Give a TRUTHFUL account of alcohol, CBD or drug use.
• Document, honestly if you are not taking medications as prescribed due to being too costly or causing bad interactions. Keep updated list in your three ring binder.
• Give specific drug sensitivities and allergies…do you get a rash or do you get short of breath, be specific with each medication. Review ALL prescriptions and over the counter medicines with a pharmacist when given any additional medications as well as, annually.

A health history becomes more helpful, if you have chronic illnesses to manage better, in tracking flare-ups and their possible causes. For instance, noting when you began a new medication might explain a sudden spike in blood pressure, cough, ringing in the ears or onset of nausea. Identifying the problem may find the solution to be as simple as taking meds separately.

Having a record of your past medical history and current health will be vital when your time is limited during a doctor’s visit. Information a doctor might need to diagnose and treat you will be at your fingertips. Knowing which tests and treatments you’ve already had might keep your doctor from unnecessarily repeating them. Having your own records is also helpful when you travel, or if you add new doctors. Having organized documents or file with specific information can be critical when a family member needs to assist in your medical care or make decisions on your behalf.