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Recording a Health History: The Basics

Article Highlights

  • Be sure to note blood type and allergies
  • List all prescribed medications
  • Keep track of examination dates and results

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»

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