I have discovered that as we grow older our medical history grows older and longer  too. It seems as though all the things we’ve had done, all the tests, all the surgeries, all the accidents just blend together into one somewhat unpleasant experience. Even if you have been relatively healthy and accident free though, knowing what tests you have had, and when you had them, and sometimes where - will help you and your doctor to keep your medical problems to a minimum through careful follow-up.

Contrary to popular belief, doctors are only human <smile>, and you too are only human. Remembering every procedure, test, important illness or allergy can be taxing. Some patients take so many medications that the only way they know them is to read the bottles.

To make out your medical history sheet you will need to gather some information about yourself. At first this may seem time consuming, and annoying, but once you have the first sheet done, updating is very easy and it makes your life much easier in the long run.

Firstly, you will need to create a page with your name, address, city, state, zip and phone number. If you have an email address, add that too. If you have a web site, go ahead and add that too. Many doctors are now using web sites and sending e- mail to their patients in order to keep them apprised of office policies and changes in medical requirements often requested by your insurance carriers or Medicare. 

Next you’ll need to make a medical release form. This is simple. (See the form listed  as Medical Release Form). Sign it and date it and mail it to each of your current doctors and to any doctor you have seen in the past FIVE years. This should include your dentist. Next you need a compilation of these histories.  So sit down and go through them step by step.

Most medical histories are easy to follow and formulated in much the same format:

Look for the description of you. It will read something like this:

Jane Doe is a 45 yr. old female who presents looking stated age with cc: stomach pain. (chief complaint).  The patient is obese (it will say this if you are as little as 10% over your ideal weight.) So if you should weigh in at 110 lbs. and your weight is 125 lbs, you may be listed as obese! There will be a physical exam that talks about your body systems in order from head to toe, front to back. The next paragraph will usually indicate a plan. For example, a list that maybe looks something like this:

1)      US of stomach (ultrasound)

2)      R/O appendicitis

3)      Labs

4)      Urine

Next will usually be a summary of what his/her “Impression” is. It will be another list.

Lastly, the doctor might say something like "Thank you Dr. Jones for referring this very pleasant woman to me", if you were referred by one of his colleagues.

Ok, now you have an idea what it looks like. Each one should be fairly similar. Glean the important information from these reports by using a yellow marker to get JUST THE FACTS.  You will use these on your compact medical history form.

Partial list of abbreviations commonly used on these forms:

ASA = Aspirin

BID = twice daily

B/P = blood pressure

bx = biopsy (OR behavior depending on which medical discipline uses it)

cm= centimeter

C/P = cardiopulmonary status (heart & lungs)

DM = Diabetes Mellitus

Dx= Diagnosis

Fx = fracture

F/U = follow up

EES – erythromycin

HTN = hypertension

Hx = history

mg = milligram(s)
mgm(s) = milligram(s) also used

NPO = nothing per oral (nothing by mouth)
PCG = Primary Care Giver

PCN =  penicillin

PE = physical examination

PMD = Primary Physician ( Primary Medical Doctor)

prn = as needed

pt = patient

PT = physical therapy
px = past (as in past history or px hx)

QD = daily in a.m.

QOD = every other day

Q hs = daily @ bedtime
QS = every shift or can also be used as (QS or qs) to mean quantity sufficient

Rx = prescription

R/O = rule out

TID – 3 times daily

UTI = urinary tract infection

WNL = within normal limits