Personal Medical History Template

A list of current medications and a concise medical history is good to have when visiting any provider. It can help assure that any pertinent information your provider might want to know is available. Here is an example of a brief but thorough medical history. It can give you an idea of what to include.  You may also want to write down your top priorities for that visit. That might be obtaining a referral, managing a symptom, or concerns about side effects from a medication. Making a list of your top three priorities can help both you and your provider focus on what’s most important to you for that visit. 

Click here to open file

Example:

First Name, Last Name DOB XX/XX/XXXX

Insurance: XXXXXX

Insurance Number: XXXXXXXXX

History as of MM/YYYY

Occupation: list occupation Habits: Smoking, alcohol, recreational drugs, caffeine Recreation: exercise, relaxation

Allergies:  Drug/food name – symptom 

Medications: Daily medications including over the counter medications: Drug name, dose (10mg), schedule (in AM)  Supplements: Supplement name, dose, schedule
As needed medications: Drug name, dose
Problem List: Interstitial Cystitis/Pelvic Floor Dysfunction Endometriosis (list areas of known) Hypothyroidism

Surgeries/Therapeutic procedures:

YYYY Procedure name brief description (City, State) – examples below
2009 Total Abdominal hysterectomy with left oophorectomy (converted from LAVH due to extensive dense adhesions and fixed pelvis).  Pathology positive for endometriosis, adenomyosis, fibroids (Dr Gyn, City, State)
2010 Robotic excision of extensive endometriosis, appendectomy, ureterolysis, cystectomy from right ovary with ovarian suspension, bilateral salpingectomy.  Hand assisted laparoscopic low anterior bowel resection.  Disease extensive and included pathology (15 biopsies sent) confirmed endometriosis of nearly entire pelvic peritoneum, fallopian tubes, ovary, appendix, rectum and sigmoid colon, ureters, right hypogastric artery, pelvic sidewalls.  Retroperitoneal fibrosis. (Dr Endo Guru, City, State) – Pelvic Floor and traditional PT post op
2013 Botox to levator muscles (Dr Endo Guru , City, State) – Pelvic Floor PT after procedure
2014 Hemi-laminectomy L4/5 with microdiscectomy (Dr Back, City, State) – PT pre/post op

Diagnostic tests:

YYYY Diagnostic test (CT, MRI, colonoscopy) – brief findings (there should be brief sentence or two on the report – examples below)
2009 Abdominal CT – obstipation
2010 EGD – esophagitis
2013 MRI left hip – labrum tear, non-displaced
2014 Colonoscopy, EGD – hemorrhoids, otherwise normal colon; erosive gastropathy
2014 MRI LS spine – T11/12 – 8.6 mm left paracentral disc extrusion with encroachment on thoracic cord; L4/5 Broad based posterior disc protrusion with encroachment upon the L5 nerve roots. L5/S1 Small central disc protrusion without significant canal stenosis.  S2 6mm prolonged signal intensity – possible Tarlov or other nerve cyst

Treatment plans (as of MM/DD/YYYY):

Problem name Brief description of treatment – see examples below
Hypothyroid Replacement tx: levothyroxine 100mcg, levothyronine 5mcg daily.  
DDD with L5 left radiculopathy, mild right foot drop Carbon fiber brace for leg (for hiking, running), walking desk for telework, standing desk in office, yoga/pilates)
Interstitial Cystitis/Pelvic Floor Dysfunction Avoiding trigger foods and activities, bladder instillations (monthly at home for maintenance, more for flares)

Contacts:

PCP  Provider name | Phone:  Clinic name, location
Pelvic Surgeon Provider name | Phone:  Clinic name, location
Pharmacy Pharmacy Name| Phone: 
Spouse/partner/support person Name | Phone:
Emergency Contact Name | Phone:


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