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March 5, 2008

Completing a medical history form at a doctor’s office

By Doug Herman The Tribune Star Wed Mar 05, 2008, 10:10 PM EST

TERRE HAUTE — These days, when you visit a doctor’s office for the first time, you are given a form on which you are supposed to record important facts about your medical history. Unfortunately, these forms ask for considerable information, much of which few human beings can recall. More unfortunate yet is that different doctors use different forms. Consequently, we are required to fill out medical history forms calling for essentially the same information all over again for each new doctor.

This column examines the kinds of information needed to complete medical history forms and what to do when you cannot recall what you are supposed to recall. First we will describe the nature of medical history forms in doctors’ offices and how these forms challenge our memory. Second we will consider how to recall immunizations you have had. Third, we will address how to recall past medical problems including illnesses, diseases, disorders, and surgeries.

The Nature of Medical History Forms

Medical history forms ask patients to record: what immunizations they may have had: and what medical problems they may have had (Illnesses, diseases, disorder and surgeries), along with the medications used to treat the medical problems. Also, the forms often ask when immunizations and medical problems occurred. In addition, different kinds of specialists want to know aspects of our history that other doctors could care less about.

Obviously, it is in our best interest to avoid guessing and provide doctors with the most accurate information possible about our medical history. However, current customs do not lead patients to record the very best information on the medical history forms. For example, patients are often not required to bring documents to an appointment to verify all of the answers provided on a medical history form. Similarly, patients are usually not asked to verify their answers on the form with a relative or a friend. As a result, patients sometimes guess when answering the questions on a medical history form. Guesses do not help doctors and medical staffs treat patients. Given this situation, we should strive to recall the required information correctly.

Immunizations

If you ponder long enough whether you have had a particular immunization, you might recall whether you actually had it. So sit in the most comfortable chair in the doctor’s waiting room. Relax all of the muscles in your body. Then let your mind drift back and back, way back. Imagine a day at preschool when a strange adult showed up in a white jacket. Imagine the pain you felt when you were inoculated. Remember screaming. Now try to recall the name of the immunization and when you had it. Hmmh. Lets try a different method.

Sometimes we remember better if we are provided some clues. You know that many immunizations are given to young children. So you might try to figure out whether you had immunizations as a child for some of the following diseases: diphtheria, tetanus, whopping cough, polio, measles, rubella (German measles), mumps and polio. Also you might recall a rough date for when you had the immunization. If you think that you had one or more of these immunizations, chances are that you had them between 2 months and 6 years old because that is when most of these immunizations are given. Some immunizations, such as for hepatitis, pneumonia, and the flu, are usually given when we are older. If all attempts to recall an immunization fails, a popular answer is DNK (that is, you “do not know).”

Medical Problems

Many medical history forms ask whether you may have had one or more serious diseases or disorders, such as cancer, diabetes, heart disease, high blood pressure, kidney disease and others. Also history forms ask whether relatives have had these medical problems. You will also be asked to report any surgeries you have had.

Chances are that you will recall your serious medical problems but if you are not sure that you have recalled all of these problems, a good way to get yourself to remember them is by sketching out a time-line of your life and by making notes by the year on the time-line when you had these medical problems. If you have difficulty recalling your surgeries, excuse yourself and go to the restroom where you can check your body for any scars from operations you may have forgotten about. Once you have a time line constructed for your medical problems, you also will be more able to remember medications you have taken for the medical problems you have put on your timeline.

Finally, you can develop a relatively accurate medical history form if you go a little early to your first appointment with a doctor.

Doing so will provide you time to concentrate, think of clues, and recall (or make an educated guess) about your history. Also, after you hand in your medical history form, ask a staff member there to make a photocopy of it.

Later, update this completed form with any medical records you have and with what relatives and friends tell you about your medical history. Take this updated medical history form to future doctors appointments and it will be easy to complete the next medical history form.

Someday a medical history database will probably be created that would hold the medical histories of all of us. Some hospitals and government medical systems have such a database now.

There are forms on the web that could be used to record a person’s medical history and that could be stored in a database on the Web.

Once there is a database accessible by doctors in general, we patients will not have to struggle to remember our medical history over again each time we visit a new doctor. We will have to make such a struggle with just the first from we complete.

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