How to Summarize Your Own Medical History

Step-by-Step Guide

1. 1

   Step 1: Request records from your primary care doctor.

   Explain that you are trying to maintain a personal health record, that they have your records and that you need and have every right to access them.
   
   If the office is using a modern computerized charting system, or if the doctor has been particularly diligent with the paper charts, a "Front Sheet" or "Cumulative Patient Profile" (CCP) may already be available to print or photocopy.
   
   If available, use the CCP to assist with the following steps.
2. 2

   Step 2: Write down your demographics.

   Include the following:
   Full name Date of birth Sex Health insurance information (provider, policy number) Next of kin and/or Power of Attorney for Care Addresses and phone numbers Name and phone number of primary care provider Name and phone number of pharmacy ,, Specialized treatments such as chemotherapy, drug trials, medication injections Over-the-counter medications, i.e., Tylenol, Gravol Herbal remedies, vitamins and supplements Cigarettes per day Alcohol consumption per day (average), week, or month Recreational drugs, if any (marijuana, cocaine, etc.) , Most recent sets of blood work (if there has been a significant change, include the older set too) Written report of x-rays and scans (there is no need to bring the actual films or CD unless seeing a specialist in that field) If you have ever had any cardiac issues, a photocopy of your most recent electrocardiogram (ECG).
   
   This is very important, as most cardiac care is time-dependent. , For instance:
   Full Code
   - If you are unable to say otherwise, all medical measures will be taken, including life support.
   
   DNR
   - "Do Not Resuscitate" No CPR, no ventilation, no life support No blood transfusions Organ donation authorized , Sign and date the sheet.
   
   Keep this emergency information with you at all times.
3. 3

   Step 3: List your medical

4. 4

   Step 4: surgical and family histories: All known medical diagnoses

5. 5

   Step 5: past and present All surgeries

6. 6

   Step 6: with name of surgery

7. 7

   Step 7: and outcome Allergies

8. 8

   Step 8: especially to medications

9. 9

   Step 9: and what reaction you had Names

10. 10

    Step 10: specialties

11. 11

    Step 11: and phone numbers of any physicians who are still following you List significant diagnoses or severe illnesses of close family members

12. 12

    Step 12: such as parents and siblings.

13. 13

    Step 13: Include a complete list of the medications you are taking: Prescription medications including dose and number of times per day taken.

14. 14

    Step 14: Summarize the results of any medical tests you have access to.

15. 15

    Step 15: Consider writing advanced care directives if you consider yourself elderly

16. 16

    Step 16: have ever had any life-threatening conditions or have specific care requests.

17. 17

    Step 17: Type out all the info on one side of a single sheet of paper.

Detailed Guide

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