Freeman Medical Musings Blog

The Importance of Keeping a Health History & What to Include

Posted by Dr. Sarah Moran, on May 08, 2014

Keeping a personal health history is important. Not only can it save you time and money by avoiding unnecessary tests and procedures, it could also save your life.

Keep a card or sheet of paper in your purse or wallet with the following information:

Past medical history: Include all diagnoses that you've received from a medical provider such as high blood pressure or thyroid problems. Also include any history of stroke and record of childbirth. No problem is too minor – for example, knowing that you have dental decay is important because cavities can increase risk of heart disease.

Past surgical history: Include minor procedures such as cataract removal and colonoscopy/endoscopy as well as major procedures such as hysterectomy, cardiac stents and gallbladder and appendix removal. By knowing what has been done, you can help avoid unnecessary tests such as a gallbladder ultrasound for abdominal pain when you've already had your gallbladder removed.

Family history: Include important things such as diabetes, heart attacks, stroke, cancer and thyroid disorder. Also include inherited diseases such as muscular dystrophy or cystic fibrosis because these can give doctors clues to diagnoses that are not initially considered.

Prevention services: Include dates and results of last Pap test, mammogram, PSA, colonoscopy and bone density testing. This can also help you avoid redundant testing and enhance prevention of life-threatening diseases.

Medication allergies and intolerances: Include a list of medications that you cannot tolerate and be sure to list the reason why you cannot take each medicine. In some cases, the drug "allergy" may actually be an intolerance, and knowing this could save your life if a certain medicine is needed to treat a disease, such as a drug-resistant bacterial infection.

Current medications: Include dose and frequency, reason for taking medicine, how long you have taken the medicine (months and years), name of the prescribing physician and your pharmacy name and phone number.

Contact numbers: Include the name and phone number of your emergency contact person, the person who has your power of attorney, and primary care physician. If applicable, be sure to include your advance medical directives, which may include instructions such as "do not resuscitate" or "do not intubate."

Having this information available makes check-in easy with each and every doctor visit. Additionally, having it accessible in your wallet or purse could save your life in an emergency situation. If you need help composing your health history, ask your family doctor for help; he or she should be able to provide you with needed information.