Articles

“Medical history and current medications” documents

 

By Melissa Geraghty, Psy.D.

“Medical history and current medications” documents

Create your own and take charge of your health care.

 

In my personal and clinical experience, when a person has chronic pain, they eventually must see yet another new specialist. Other than the potential of meeting with a compassionless doctor, the part I dread the most is having to retell my extensive medical history, which includes filling out new patient forms. That is why I created a personalized text document: “Medical History and Current Medications.”

 

I update this “living document” anytime I receive a new diagnosis, have a change in my medication, undergo a medical test, etc. This way, before any upcoming appointment, I am not stressed with scrambling for my medical history and do not have the burden of trying to remember everything I need to for the appointment. (Thanks, Fibro Fog!)

 

Many people with chronic pain acquire new difficulties and diagnoses over the years. After 20+ diagnoses, it would be difficult for me to keep track of everything if I hadn’t created this document! It is also good to have this document in case your doctor is on vacation or goes on maternity leave and you need to see someone else at their practice. Most importantly, having a document like this is the epitome of being a self-advocate.

 

The day before any new appointment, I print out an updated copy for myself, and for the doctor’s chart. On the new patient form, for the more extensive portions that are already in my printed document, I simply write “please see attached document.” This saves a lot of time and energy.

 

Here are the 12 sections I created for my “Medical History and Current Medications” document:

 

  1. Basic Information. Include your full name with middle initial(s), date of birth, home address, phone number (home, work, and/or cell), email address, and date the document was last updated.
  2. Current Medical Team. Include your team members’ names, their credentials, practice name, and phone number. Examples of members to include: primary care physician, pain physician, pain nurse practitioner, pain psychologist, physical therapist, occupational therapist, rheumatologist, gastroenterologist, gynecologist, massage therapist, etc.
  3. Medical Diagnoses. Include each diagnosis and the month/year diagnosed. Include if the diagnosis was brought on by something (for example: the neuropathy in my left arm was caused by a tetanus shot).
  4. Current Medications and Vitamins. Include the name of each medicine or vitamin (including the brand name), dose, frequency taken (including what time of day/night), when you started taking it, the reason it is prescribed, and who prescribed it. Make sure to also list PRN (or “as needed”) medications.
  5. Medication Allergies. Include any medication allergies, and the symptoms you experience (for example: morphine = severe migraine).
  6. Discontinued Medications and Discontinued Vitamins. Include the names of medications or vitamins (including the brand name), dose, frequency taken (including what time of day/night), when you started it, the reason it was prescribed, who prescribed it, date stopped, and reason stopped.
  7. Include the type of each surgery, reason for surgery, date of surgery, who performed the surgery, the hospital location of the surgery, and outcome.
  8. ER Visits and Hospitalizations. Include each date of visit, name of the hospital and doctor, reason for visit, length of stay, tests/results, medications, and outcome.
  9. Recent Test Results. Include the name of the test, the doctor who ordered it, why the test was ordered, when the test was administered, and a brief summary of any results. Examples include bloodwork, EKG, MRI, etc. (So that this section does not become pages and pages long, for this document I only include tests from the past three months—but you can customize for your situation. I keep older test results in a separate document so I can easily reference them if needed.)
  10. Detailed History of Complex Medical Conditions. Include as much detail as you feel is important for a new doctor to understand. For example, mine includes a bulleted, timeline-like section about my complicated GI history, which includes specialist doctor visits, hospitalization details, a detailed list of symptoms and pain experiences, medical tests and medications provided, and procedures performed.
  11. Family Medical History. Include a brief medical and psychological background on your parents, grandparents, siblings, and any significant medical diagnoses of extended relatives. Include the date and cause of death for any family member as applicable.
  12. Include any current symptoms, concerns, or questions you would like to discuss during your appointment. You can also use this page for jotting down notes during your appointment. At the top of your Notes page, include the date of the appointment, which health care professional you are seeing, and if there is a specific reason (like a post-procedure follow-up, or meeting a new specialist). This way you will have a record of what occurred in each of your appointments for later reference.

 

You may not need all of these sections, and you can customize this document to meet your needs. I keep the printed version of this document in a folder or binder—this will become your “going to the doctor binder.”

If you want to be super-organized, you can even have tabbed sections or pocket folders representing different aspects of your medical care. I suggest that the first tab be your “Medical History and Current Medications” document, and your second tab be the Notes section so it is easily accessible. Sometimes physical therapists give instructions for at-home exercises and may provide handouts, so Physical Therapy can have another tab/pocket, and so forth. The possibilities for tabs are endless!

If you are feeling creative, decorate your binder to suit your personality since you will be taking this binder to many appointments—it may as well be visually pleasing.

Initially, creating this document from scratch can be a stressful process—but it is worth it in the end. I hope this document empowers you while navigating the health care system. Stay mindful, fellow pain warriors!