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How to Make a Health History Sheet

Author: Dr. Handal, MD

Be sure to write and pronounce the information clearly. Is your spelling correct, especially in regards to medication? Is your handwriting legible? If you write like a doctor, consider typing your medication list, using the information on the medication bottles as your guide. When you say you're on Clonidine, which is for high blood pressure, does it sound like you're saying Klonopin® which is for seizures or Colchicine for gout?

You should keep a folder at home with all your medical history documents, along with a dated summary of your medical history and current medications. Whenever possible, bring a copy of the summary with you to the hospital. It's best to carry a copy in case the information isn't returned to you.

Here's a sample Health History Sheet (Medical History / Medication List):

Name: Mary D. Smith (Include middle initial!)

Date: March 1, 2013 (last updated)

Date of Birth: 1/1/1955

Physician's Name(s)/ phone numbers, (Include area code) Dr. Barry Jones, General Practitioner 401-332-3333; Dr. Lee Stark, cardiologist, 401-523-3343

Insurance Company/ phone number: ACE Insurance, 800-444-1111

In Case of Emergency (ICE) contact person / Phone numbers (Include area code): Don D. Smith, son, 443-323-2333 (home), 443-230-4655 (cell)

Clergy: Rev. Brian Clifford, 401-232-1131

Allergies: Penicillin (rash), Latex (rash), Shellfish/Iodine (anaphylaxis)

Very important!! List all medicine, food, and environmental allergens. If you're allergic to penicillin, describe the type of reaction you had when you took it; for example, penicillin (rash). Allergies to shellfish are important to mention because some contrast dyes used in medical testing contain iodine. Latex allergies are also important to note because latex is used in medical equipment and gloves. Again, specify the type of reaction you had. An upset stomach alone is not an allergic reaction.

Medical History: Hypertension (diagnosed 1999), Insulin-Dependent Diabetes (diagnosed 1999), Heart attack (2000), Diverticulitis, Cancer Left Breast (2002), Hypothyroidism (diagnosed 1999)

SURGERIES: Left mastectomy (2003), Appendectomy (1993)

Implanted Devices: Pacemaker Left Chest Wall (2012)

Remember, if you are being treated for a condition, even if it is well controlled, you still have that condition, so list it! List body parts affected. For example, if you had a mastectomy, specify left and/or right breast. Note on this paper if you have any metal in your body, including implants, shrapnel or implanted medical devices.

Family History: Lung cancer (mother, deceased 1999), Diabetes (father) Hypertension (brother)

You may also be asked about your family's health history. Make a note if anyone in your family has had: diabetes, cancer, hypertension, heart disease, aneurysms, as well as any hereditary conditions.

Current Prescribed Medications:

Two Lasix 20 mg (total 40 mg), twice a day for high blood pressure

Aspirin 81 mg, daily

Fexofenadine HCL, 180 mg, daily for allergies (stopped 1/2/2013)

Simvastatin, 40 mg, daily for high cholesterol

Be sure to note the dose along with how many of each pill you take and how often. For example, if you take two 20 mg doses twice a day, spell it out so there's no confusion. State also what condition do you take the drug – medications for high blood pressure are also given for irregular heart rate. Brand names (®) versus generics names can contribute to the confusion.

Doublecheck your spelling, pronunciation and the dosing information against the bottle.

See how easy it is to make a mistake: Salagen® 5 mg v. Selegiline 5 mg

Salagen is prescribed for relief of dry mouth symptoms and glaucoma. Selegiline is prescribed to treat Parkinson's disease or depression. Both products are available in 5 mg tablets!

Over-the-counter (OTC)/Herbal preparations:

Co-Q, Red YeastRice, Vitamin C, Calcium, Gingko

This is important! Your health care team needs to know if you're taking any over-the-counter (OTC) medications because they, too, have side effects and can interact with other medications. The use of topical sulfa ointments on cuts is a great example. These ointments contain an azo dye, ‘aseptil rojo' that can make your urine red! So if you go to the ER because you think you have blood in your urine and you don't tell them about this medication, lots of time and money will be spent trying to figure out what's wrong with you. Another example is the use of red yeast rice which when taken in high doses acts like a statin (class of cholesterol lowering drugs) medication and can cause liver disease and breakdown of skeletal muscle. So tell what you take and how often.

Vaccination dates:

Flu Vaccine: 11/1/2012

Pneumonia Vaccine: 10/20/2005

Tetanus: 2/3/2009

The medical professionals who treat you will appreciate the time and effort you have spent maintaining your health history information. Believe me, you've gained their respect by helping them do their jobs.

The nurse is going to look at your list of medications and ask you when you last took each. If you are admitted to the hospital, chances are the Hospitalist is going to order the drugs on this list for you, along with medications needed to treat you now. Make sure the list you provide is current and dated! Don't add new medications to the list without deleting the old ones you stopped taking! List if stopped within a month.

In some communities, health history and medication information is kept in the refrigerator and a marker is placed on either an entrance door or refrigerator door, alerting emergency personnel to its whereabouts. You can contact your local fire department or ambulance service to determine if this practice is common in your community and what you can do to participate.

Article Source: http://www.articlesbase.com/medicine-articles/how-to-make-a-health-history-sheet-6511364.html

Kathleen A. Handal, MD (DocHandal) is a long-standing believer in consumer education; she knows it does make a difference. Her thesis is that "we physicians need to come down to the consumer's level to bring them up towards ours". She has a website dedicated to sharing medical common sense (www.dochandal.com). Through the iTune store, her free podcasts are available at her Channel DocHandal Speaks-Listen-UP! She authors and publishes 'Doc Handal's Guides', as e- and print books available at Amazon, iBooks, Smashwords, Kobo and Dieselibooks. "Doc's First Aid Guide" is available in Spanish & French. "Doc's ER Survival Guide" gives an inside view and tips on survival. She is well understood, as she uses simple yet accurate examples in non-medical terms. Dr. Handal's first book, "The American Red Cross First Aid & Safety Handbook was written for the lay audience. She is a trained emergency physician with over 25 years of patient care experience. Presently she is a Senior Consultant ASSERT INC (Associated Systems for Search Education Research and Training) and an educator. Popularity and visibility with non-medical persons landed her hosting talk-radio health shows. She has also made TV appearances on CNN and the Today Show. DocHandal has won an International Cindy Competition (Bronze Medal, 1993) and Telly Award (Finalist 1993) for medical videos focused for workplace emergencies. She wrote, directed and produced "Trauma Run", (1996) a nationally distributed video (K2-6). This video (in Spanish and English) is designed to teach children how to respond and what to expect from emergency medical personnel when no adults are available.

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