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Your Medical History

By Dr. Peter W. Kujtan, B.Sc., M.D., Ph.D.

Article printed on page 30 in the June 25-26, 2005 issue of
The Mississauga News under the feature: Health & Wellness, Medical Matters.
Portrait of Dr. Peter W. Kujtan, supplied 2005
Dr. Peter W. Kujtan

There are multiple ways in which you can be your own best Health Care Advocate. One of the most practical temporary solutions to the continually archaic information transfer system is to keep a simplified version of your health record. This can be easily accomplished with a pre-printed form available through most doctors' offices, or more elaborate versions on CD or diskette. These are a godsend when patients with complicated problems, multiple medications and fragile health find themselves in unfamiliar places. Handing one of these to the examining physician will ensure better and perhaps quicker care. Handing it directly to a physician will preserve your confidentiality.

What to include? Start with your name, address, birth date, health card number and contact numbers as well as those of relatives that would make useful contacts if the need arises. Try to be as concise as possible. Next, write a short 3-4 sentence description of why you are seeking medical assistance. Make simple statements such as "my stomach feels like someone is stabbing it" or "my temperature was 39C last night". Try not to include trivial things or make diagnoses yourself. Examples of these include "I don't feel well" or "I have the flu". Then go on to list any other health conditions that you suffer, e.g. hypertension, high cholesterols, osteoarthritis, etc. List any medications that you are currently taking, or have recently stopped taking along with the doses and frequency. Include all herbs, vitamins and over-the-counter medications. State if you are allergic to anything. In the next section, list all health professionals whom you have seen in the last year or whom you see regularly. Be sure to include their phone numbers, specialties, and the last time you saw them.

This should be followed by any operations that you have had in your lifetime and the approximate year of surgery, including obstetrical procedures for women. In this section, it is useful to include any major injuries and broken bones that you may have suffered. Below this, list as many tests as you can remember, along with the dates and locations. Examples include: CT-head-2004-Trillium, Ultrasound-kidneys-1996-2000 Credit Valley Rd, Breathing Test-1997, Blood Work-2005-family doctor.

More elaborate versions include information about caffeine, nicotine and alcohol use. Listing diseases found in your family tree is also helpful. In medical school, students are given a full hour to interview patients and compose this history. In the real world, the average medical interaction for urgent care is measured in minutes. Compiling this record requires a fair amount of effort, but it pays off in overwhelming dividends, because you receive better quality service. Storing the whole thing on a disk or re-writable CD allows for changes to be made as well as uploading medical test data, digital radiological and cardiac images and notes for your family doctor.

This is not a new idea. A health "smart card" which incorporated a microchip into the health card was invented over a dozen years ago, but shelved. It had the ability to download all pertinent information for health-care providers to share. Confidentiality issues in health care are spiraling us into a frenzied paranoia and stifling ventures aim to provide better health care. Simply read the new "privacy act" legislated last year. The fallout is only in the vestigial stages. The onus has been placed on physicians and institutions to take extraordinary measures to safeguard information. The end result is to generate a new mountain of paperwork on top of the existing mountain, crippling the ability to share information that may be vital to the maintenance of health. The faxing or photocopying of information has been restricted and made more difficult with the need to have patients sign waivers and cover costs at every turn. My own after-hours clinic can no longer inform me when my patients attend the clinic, unless they fill out and sign the consent form. Patients end up unwilling participants alongside their doctors in this paper jungle, and waiting rooms are littered with people busily pondering clipboards. Some of my patients end up doing more paperwork than I do during the course of their visit. I only hope that we are not "safe-guarding" ourselves to death. I think this scheme rates another "tick" on the family doctor extinction clock.

Related resources:

Personal Medical Records from MedlinePlus.

Family Medical Records from eMedicineHealth.

Keeping a Personal Health Record to Insure Proper Health Care from CareCounsel, CARECOUNSEL TIPS: Value of Keeping a Record, Information in a Health Record, Other Documents to Keep in the Record.

Personal Medical Record Form - in PDF. Sample from St. Luke's Episcopal Health System.

Personal Medical Records - Form. Printable sample form from United Services Automobile Association (USAA) Educational Foundation. Contents: Whom to notify in case of emergency, Blood type, Physicians, Insurance information, Medical and mental health, Surgical procedures, Allergies, Medications, Hospitalization or ER visits for other reasons, Test results, Preventive health/Health maintenance, Family history.

Creating a Health Journal includes example of a health journal from familydoctor.org - American Academy of Family Physicians.

Personal health record-keeping gets popular in US from E-Health Insider News.

Your Personal Health Record. Commercial site. Includes some example pages: Who is your emergency contact? What is your cholesterol? What medication are you on? What was your last blood pressure? Are you travelling?

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