Health History: Write it Down
Older people often have a lot to juggle—and to remember—when it comes to their health. They may take medications for one or more chronic conditions. They might see several different specialists besides their regular family doctor. And they might undergo a laundry list of routine tests. Trips to the doctor, pharmacy, and lab may take up much of their time.
It’s easy to forget important information about your health at any age—your last physical, your last health screening. This may interfere with good care as these are facts that doctors need to know to treat you properly, and that you need to know to stay healthy. But there’s an easy solution—write it down.
If you’re helping to care for an older relative or your parents, record health information in one place and have one less thing to worry about. And if you don’t have your own written health record, now’s the time to start one.
How to Record Health Information It doesn’t take a lot of time. Just be consistent. The great thing about a written health record is that it gathers health information in one place. You won’t have to call the doctor’s office or look back through old calendars or checkbooks to see when your parent’s lab test or eye appointment took place. And you’ll have all the information ready for the next doctor visit.
You can find boilerplate records in a number of places. You can download medical history charts from different health Web sites or copy them from books. You can go to a bookstore and buy a health journal, or you can just use a simple notebook. Doctors sometime provide booklets in their offices. Choose what works for you.
No need to record every cold or sore throat, but the more thorough you are, the better. Here are some important categories. Create a page or several pages for each, depending on how much information you think you will have. Arrange it however you or your older relative would most easily find it.
General Information This section should go at the beginning and should include:
- Your name and the name of your older relative
- Telephone number
- Birth date
- Social Security number
- Family doctor’s name and telephone number
- Name of health insurance company, member number, and telephone 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, bees, 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 all providers here, their specialties, their telephone numbers, and the condition they’re treating. Include home-care providers and any others such as acupuncturists, massage therapists, or chiropractors. Some examples:
- Primary care physician/Geriatrician
- Eye doctor
- Ear, nose, throat specialist
- Foot doctor
- Heart specialist
- Cancer specialist
- Orthopedist (specializes in bone, joint, and muscle problems)
- Gastroenterologist (specializes in diseases of the digestive tract)
- Endocrinologist (specializes in diseases of the glands)
- Psychologist or social worker
- Physical therapist
- Nutritionist or dietitian
- Visiting nurse
Medications List all prescribed medications, the reason they were prescribed, and the doctors who prescribed them. Include the start date and dosage. Any vitamins, herbs, supplements, or over-the-counter medicines taken regularly also should go here.
Health Conditions This section should list conditions such as arthritis, osteoporosis, or high blood pressure. Also include all hospitalizations, the reasons for the stay, and their durations and outcomes.
Exams, Tests, and Screenings Include dates and results of examinations, tests, and screenings here, including physicals. Record your height, weight, and blood pressure. Jot down after each entry when your loved one will need to repeat each of these checks again. Be sure your loved ones get screened for the following kinds of conditions:
- Eye and vision problems
- Dental problems
Shots List dates of shots for flu, pneumonia, tetanus, tuberculosis, allergy, and other shots.
Family Medical History It’s a good idea to include a family medical history as best you can. Write down the names of family members who have had cancer, heart disease, dementia, mental health problems, diabetes, and other conditions. If you can remember or get the information from relatives, write down how old family members were when they had their conditions. If they’re deceased, record the cause of death.
Questions to Ask the Doctor Good health care arises from good communication and information. Patients should understand what doctors, pharmacists, and other health care providers are telling them—and speak up if they don’t. Doctors need to address patients’ concerns clearly and thoroughly. If possible visit the doctor and jot down some important questions to ask before your visit. You might want to include:
- What the problem and what are the treatment options?
- What is the most effective treatment for this problem?
- If medication is prescribed, how long should it be taken and what are the side effects?
- Are tests needed? What preparation is needed, what will they show?
- Should there be a follow-up visit?
Begin Where You Are If you or your parents haven’t kept organized health records, it may overwhelm you to start now. Don’t worry—it’s not too late. Just begin where you are. Record the date and reason for the next doctor visit. Keep the record in an easy-to-reach place and add to it when your loved one returns to the doctor, receives test results, or fills a prescription.
Once you start your parent's health record, go back and fill in sections a little at a time. It’s okay if you don’t remember every illness or doctor visit. Write down what you can. Over time the journal will take shape, and your loved one and their health care providers will be grateful for your efforts.
© 2003, 2004, 2007 AARP. Reprinting by permission only.