The Patient’s Advocate

The Patient’s Advocate – Helping You to Navigate the Healthcare System
Something most of us have in common is doctor visits. If you have seen the doctor any time in the last few years, you have probably noticed an increasingly complicated system-more forms, more ancillary staff, a computer in the exam room, and briefer face to face time with the physician. And let’s hope you do not have to experience the hospital admission process!

So, one efficient tool to help you navigate this increasingly complicated healthcare system is a Health History sheet. It can be a simple 3” x 5” card or a complex color-coded chart. What are the benefits? A busy mom may not remember if it was John or Joe who had the medication reaction. This tool may prompt the person to clarify with a family member before the appointment regarding childhood surgeries or illnesses. If faced with multiple health problems, this sheet may facilitate the exchange of information with new specialists. And, in the event of an emergency, this information carried near the driver’s license provides the emergency response team an advantage in treating at the scene.

(1) Start with your name and the date. If you have a common name, adding a middle name or address may be helpful. The information you share with your physician is confidential, but you could drop or misplace the sheet, potentially making your personal information, well…public. Therefore, NEVER put your social security or health insurance identification numbers on it.
(2) Allergies (if color coding your sheet, print this in red). List anything to which you are allergic AND what happens when you are exposed. (Example: Penicillin—Rash.) Include environmental exposures like bee stings or latex. Some physicians only want to document a “true” allergy which includes swelling, hives, itching, rashes, or trouble breathing. Some electronic medical records may not provide a field for a reaction such as vomiting. So you may want to create an Adverse Reactions section on your Health History sheet where you can identify other reactions or intolerances. (Example: Statins—Muscle Pain.)
(3) Medications. Keep an UPDATED list which includes all prescribed and over-the-counter medications, as well as herbal and vitamin supplements. Remove all discontinued items and add all new ones before your appointment. Don’t forget to change the date on your card so your physician knows they have the most current information. Include the name of the medicine, the strength (usually shown as mg or mg/ml (for liquids), and how frequently you take it. Example: Gabapentin—100 mg twice a day). Medications taken “as needed” such as antacids for heartburn can be listed “as needed.” Complete information reduces the potential for medication interactions.
(4) Current Health Problems. List your current health issues, including those for which you do not take any medication or those which are partially or completely controlled by your prescribed medication. Examples might include arthritis which is managed with daily stretching, or hypertension or diabetes which is controlled with medication
(5) Past Health Problems. Suppose a gout or kidney stone attack occurred ten years ago. These may be more likely to crop up again, so your doctor needs to know.
(6) Past Surgeries. Physician awareness that something has been removed, added, or replaced, may help avoid unnecessary testing.
(7) Family History. Unless there is more information than you can easily remember, this section may not be necessary. Your physician will be especially interested in cancer, diabetes, and heart disease in parents and siblings.


Ask about submitting a copy of your Health History sheet in place of completing the health history form at your new-patient appointment. At subsequent visits, hand a copy of your Health History sheet to the medical assistant or nurse to update your chart. A Health History sheet takes a few minutes to create and update, but communicates accurate at-a-glance information that your provider appreciates.