Giving our medical history over and over and over at Medical appointments can be very stressful! I can’t count the number of times I have had to layout my medical time line throughout my pain journey. While working on my memoir I had to do it again, to try to clarify certain time frames. It occurred to me it would be very helpful if we had a template of a better way to sort all our information for our Doctors.
Having been on the other side of the treatment table it also dawned on me that I love it when a client has a streamlined sheet of paper I can refer to explaining the medical part of their story.
Sharing long medical histories can be daunting. I understand, I really do. So I have outlined the things clinicians really do need to know, as well as the things I believe we as patients should share, knowing how hard it can be.
Let’s get started
Print out your free Medical History worksheet here. Medical History Worksheet
You can fill it out as you go through the post, or it will be available at the end of the post too. I gotcha covered either way. Take your time to fill it out and brainstorm!
When I did my time line for my memoir I kept adding and adding to my “prior treatments” section! 20 years is a loooooonnnngggg history. I’ll be honest, I couldn’t even remember some of the Doctors or PT’s names that I saw. I ended up just putting a city, a year, and the bits I could remember. This will help you and your medical team, so it’s ok if it takes some time to compile and you will need to update from time to time.
Some of the questions included may seem strange, or irrelevant, but believe it or not a complete medical history can be very helpful in getting to the heart of your concern. Please fill it all out.
With how short appointments can be, having your history prepared beforehand can give you and your medical professionals more time for solutions and spend less time in information gathering.
So let’s get down to business and outline the important parts of your medical history to help your providers help you!
The Basics of Medical History
Name, Birthdate, Marital status, Occupation
Report your existing medical Diagnosis and the year you were diagnosed. Things like hypothyroidism, arthritis in your right shoulder, kidney failure, glaucoma, heart murmur go in this section as well as pregnancy related information. # of pregnancies, # of children, # of miscarriage, # of abortions, # of vaginal births, # of C-sections.
Not just the surgeries that you feel relate to your pain, all of them. The c-section, the tonsils taken out when you were a kid, all of it, with dates and surgeons names. Please remember “back surgery” is not specific enough, please list the type of back surgery you had. Nice bullet point list with dates is the best way to share this.
Medications and Supplements:
List out all the medications AND supplements you are currently prescribed with the dose and frequency. This includes, your Advil, CBD oil, dietary supplements and powders and melatonin. Please don’t leave it out.
Something people often leave out is that they aren’t taking meds as prescribed. Even though that muscle relaxant was for 2 times a day, you only take it once a week, or at bed time. It’s OK to tell the professionals. Not everyone is great about taking medications, if you tell your professional they may have other ideas that are easier. Did you know pain management medications can be compounded into a cream for some situations? It can! If I hadn’t told my MD, I might not have known.
Believe me, No one is surprised at clients that don’t take meds as prescribed. Nothing surprises really surprises medical professionals much anymore. However, it is important information to share so they can help you find a situation that works FOR you.
Medical History Past and Current Treatments
Wanna know a secret, promise not to tell? The best care providers pay close attention to this section. Especially for those in persisting pain. Why? Because it tells us all the things that haven’t worked! If they had, you wouldn’t have made the appointment! The section of your health history is important because it leads health care professionals into new directions.
Start by making a list. Consider doing it by year or specialty, Just don’t leave anything out, not even the Shaman you visited on that last trip you took, the injection that doc gave you in the office, or the fascia blaster you tried twice. List them all with the date, duration and outcome.
What are you doing right now, this very second for the pain you are seeing your MD about? Remember to include home remedies as well as all the professionals.
Medical History: Your Pain
Remember to have a CHAT and not just give a number. I wrote a complete blog post on the pain scale and ways to improve that conversation with your provider about your pain here.
- Capacity – what can you do and not do because of your pain
- History – how does your pain behave what eases it or makes it worse – just the facts
- Analogy – Here is your opportunity to describe what the pain feels like, be real, describe what you feel and don’t be afraid to be flowery or poetic.
- Treatment – you covered that above!`
In addition to the CHAT, I think it is also important to include a small paragraph on who you were before your pain. When you listen to the stories of the women I have interviewed in my podcast Restoring YOU, there is a clear difference in how these women are living before and after their pain experiences. This summary is important because it speaks to who YOU are.
It can be easy to for someone listening to misunderstand who you are now. The way you make decisions now might not have always been the way you approached life or challenges. Pain can wear us down. So to help those helping us, include who you were, hobbies you loved, a quick brush stroke for them to understand even more how this pain is affecting your ability to function and live your life.
Medical History we forget to talk about
Your pain can be affected by many factors. So everything from your stress to your sexual history to your use of supplements should be disclosed. I understand some of these topics can be embarrassing to disclose. The thing is, when we share a fuller picture of what our history, it enables better care. I know for me, when I finally started talking about all “the other stuff” I was able to create a more holistic approach to my pain.
- Are you sensitive to any of the following: light, sound, fabric on your skin, temperature, foods.
- Is sexual intercourse painful? If yes, please explain.
- Do you have an increase in pain or pressure around your menstrual cycle?
- Do you have any concerns about voiding? Urination or defecation, leaking, frequency, constipation?
- Anything else you want to note around these issues?
- Life stress: your marriage, job, kids, parents, pets. If you’re often stressed or sad — or if you’re in an abusive relationship — speak up.
- Trouble sleeping – You may think this isn’t really important to talk about, but lack of good sleep can be a factor contributing to your pain experience. There are lots of ways to help yourself, and they don’t even require meds!
- Fatigue, low on energy: reasons exist for being tired, so please include this in your history if you are experiencing it.
- Why do you think you are continuing to experience pain
- What would make you feel like you knew why you were having pain
- How would you like me to help you today?
Remember, your medical team wants to help, so providing information in a concise and clear way can help them do that. It is my hope this has helped you organize your information in a helpful way.
You can also keep your medical history online and share it with your medical team. Pain- Train, is a website created by a woman who experienced persistent pain and wanted to make medical appointments easier. She created an online Patient History portal that YOU can share with YOUR medical team. This enables you to send your history ahead of your appointment so you can focus on what matters most, solutions!
Clinicians, while I was wandering the internet for this post, I found this resource. Take a read, there are great reminders in here. It reminds us to listen first and listen second.
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