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Recording a Health History: The Basics

What should I include when putting together my health history? What sorts of things should I keep track of? Here are guidelines to follow when writing out a health history.

See also: Assessing the Situation.

General Information 

  • This section should go at the beginning and should include:
  • Name of patient, date of birth, address and phone numbers.
  • Family doctor’s name and telephone number.
  • Information on health insurance company, including member and group identification numbers, as well as address and phone number.
  • Medicare and/or Medicaid number.
  • Pharmacy name and telephone number.
  • Emergency contact name and telephone number.
  • Nearest hospital name and telephone number.
  • Blood type.
  • Allergies to drugs, foods, insects, etc.
  • Special conditions, such as being diabetic, epileptic or having a pacemaker.
  • Whether a living will or health care proxy exists.

Health Care Providers
List the names of all providers, their specialties, their telephone numbers and the conditions they’re treating. 

  • Primary care physician/geriatrician.
  • Eye doctor.
  • Ear, nose and throat specialist.
  • Dentist.
  • Foot doctor.
  • Heart specialist.
  • Cancer specialist.
  • Allergist.
  • Orthopedist (specializes in bone, joint and muscle problems).
  • Gastroenterologist (specializes in diseases of the digestive tract).
  • Endocrinologist (specializes in diseases of the glands).
  • Neurologist.
  • Urologist (specializes in diseases of the urinary tract and male reproductive organs).
  • Psychiatrist.
  • Psychologist or social worker.
  • Physical therapist.
  • Nutritionist or dietitian.
  • Visiting nurse.
  • Home-care aide.

List all prescribed medications, the reason they were prescribed and the prescribing doctors. Include the start date and dosage. Any vitamins, herbs, supplements or over-the-counter medicines taken regularly should be included.

Download this personal medication record to help you track your loved one's medicines.

Next: Including dates of examinations and tests»

Health Conditions
List all conditions such as arthritis, osteoporosis or high blood pressure. Also list all hospitalizations, including the reason for the hospital stay and information about how things turned out.

Exams, Tests and Screenings
Include dates and results of examinations, tests and screenings, including physicals. Record height, weight and blood pressure. After each entry, jot down when these exams, tests and screenings are needed again. And be sure your loved one is screened for the following conditions:

  • Cancer.
  • Diabetes.
  • Osteoporosis.
  • High cholesterol.
  • High blood pressure.
  • Obesity.
  • HIV. 
  • Eye and vision problems.
  • Hearing problems.
  • Dental problems.

List dates of shots for flu, pneumonia, tetanus, tuberculosis, allergy and other ailments.

Family Medical History
Assemble a family medical history as best you can. Include names of family members who have had cancer, heart disease, dementia, mental health problems, diabetes and other conditions. Write down how old family members were when their conditions were diagnosed. If you can’t remember, get the information from relatives. Also list the names of family members who have died, including the date and cause of their death.

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