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A list of current medications and a concise medical history is good to have when visiting any provider. It can help assure that any pertinent information your provider might want to know is available. Here is an example of a brief but thorough medical history. It can give you an idea of what to include. You may also want to write down your top priorities for that visit. That might be obtaining a referral, managing a symptom, or concerns about side effects from a medication. Making a list of your top three priorities can help both you and your provider focus on what’s most important to you for that visit.
First Name, Last Name DOB XX/XX/XXXX
Insurance: XXXXXX
Insurance Number: XXXXXXXXX
History as of MM/YYYY
| Occupation: list occupation | Habits: Smoking, alcohol, recreational drugs, caffeine | Recreation: exercise, relaxation |
Allergies: Drug/food name – symptom
| Medications:
Daily medications including over the counter medications:
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Supplements:
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As needed medications:
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Problem List:
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Surgeries/Therapeutic procedures:
| YYYY | Procedure name brief description (City, State) – examples below |
| 2009 | Total Abdominal hysterectomy with left oophorectomy (converted from LAVH due to extensive dense adhesions and fixed pelvis). Pathology positive for endometriosis, adenomyosis, fibroids (Dr Gyn, City, State) |
| 2010 | Robotic excision of extensive endometriosis, appendectomy, ureterolysis, cystectomy from right ovary with ovarian suspension, bilateral salpingectomy. Hand assisted laparoscopic low anterior bowel resection. Disease extensive and included pathology (15 biopsies sent) confirmed endometriosis of nearly entire pelvic peritoneum, fallopian tubes, ovary, appendix, rectum and sigmoid colon, ureters, right hypogastric artery, pelvic sidewalls. Retroperitoneal fibrosis. (Dr Endo Guru, City, State) – Pelvic Floor and traditional PT post op |
| 2013 | Botox to levator muscles (Dr Endo Guru , City, State) – Pelvic Floor PT after procedure |
| 2014 | Hemi-laminectomy L4/5 with microdiscectomy (Dr Back, City, State) – PT pre/post op |
Diagnostic tests:
| YYYY | Diagnostic test (CT, MRI, colonoscopy) – brief findings (there should be brief sentence or two on the report – examples below) |
| 2009 | Abdominal CT – obstipation |
| 2010 | EGD – esophagitis |
| 2013 | MRI left hip – labrum tear, non-displaced |
| 2014 | Colonoscopy, EGD – hemorrhoids, otherwise normal colon; erosive gastropathy |
| 2014 | MRI LS spine – T11/12 – 8.6 mm left paracentral disc extrusion with encroachment on thoracic cord; L4/5 Broad based posterior disc protrusion with encroachment upon the L5 nerve roots. L5/S1 Small central disc protrusion without significant canal stenosis. S2 6mm prolonged signal intensity – possible Tarlov or other nerve cyst |
Treatment plans (as of MM/DD/YYYY):
| Problem name | Brief description of treatment – see examples below |
| Hypothyroid | Replacement tx: levothyroxine 100mcg, levothyronine 5mcg daily. |
| DDD with L5 left radiculopathy, mild right foot drop | Carbon fiber brace for leg (for hiking, running), walking desk for telework, standing desk in office, yoga/pilates) |
| Interstitial Cystitis/Pelvic Floor Dysfunction | Avoiding trigger foods and activities, bladder instillations (monthly at home for maintenance, more for flares) |
Contacts:
| PCP | Provider name | Phone:
Clinic name, location |
| Pelvic Surgeon | Provider name | Phone:
Clinic name, location |
| Pharmacy | Pharmacy Name| Phone: |
| Spouse/partner/support person | Name | Phone: |
| Emergency Contact | Name | Phone: |