If you haven't read part 1 of this topic, go back and do that now. Life is much easier and safer, if you have an up to date medical history in your wallet or the glove compartment of your car. Visits to the doctor or dentist or other healthcare professional can be much less of a hassle for you and for them if you can pull a sheet of paper out of your pocket, which has all the necessary information, including your medications in one place. During a visit for a medical complaint, many patients are anxious as well as feeling unwell and cannot recall things they would normally be able to. As mentioned previously, I usually have the information in triplicate , because in a teaching clinic or hospital it is often necessary to provide the information two or even three times. When I was a teacher of Family Medicine one of the most frequent complaints I heard from my patients in the teaching setting was, "Do I have to go over all that again?"
If the information is stored on your computer, it is easy to keep up to date and to print off your copies before your appointment. Unless your history is very long, you will be able to keep all the information on a single page. So, let's get started:
First, at the top if the page you need your name and address, phone numbers , email address and next of kin.
Under that, make a heading titled : Why am I here today? You just need enough space to briefly summarize your complaint. A couple of lines will be sufficient, because that is what you are here to talk to the doctor or about. You will, of course, be leaving this section blank, unless you happen to develop an acute bellyache while you are preparing the form!
Paragraph 3, will be your past illnesses and the treatment as far as you can recall. If you have difficulty you can phone your doctors office, explain what you want and in many instances the nurse will be able to give you the information. Again, be brief. If the doctor needs further information and you don't have it, he can get it elsewhere.
Paragraph 4, will be titled: Allergies and Immunizations.
If you're not aware of any allergies, a simple 'none known' is appropriate. Many older persons don't know what their childhood immunization status is, but will know what they have had in their adult life,
Paragraph 5 will be titled: "Current Medications and dosage." with a subheading "Previous Medications,(don't worry about the dosage which you prbably won't remember anyway).
Finally, 'Other physicians I have seen and hospital admissions' and voila!
By the way, there are loads of medical records applications on the internet. Many connect to a web site and I certainly wouldn't want my history floating around in cyberspace. There are a few that state your data just stays on your device, but for the most part I did not think they were as good as the above and a lot more fussy to maintain, so at present I don't recommend any and i will continue keeping my data on my desktop, and print off copies as I need them. Keep a copy in your glove compartment or in your wallet and let your family know they are there.
I'd welcome any comments if you have any ideas about this.