What should you include in a medical history document?

A medical history document allows a doctor to review a patient’s health pattern over time. Parents are also able to use the information on these forms to compare siblings. While this document is not meant to replace a doctor’s medical files, it’s a handy reference tool that can provide crucial information needed to decide on a course of medical treatment.

Each family member should have a separate medical history document. One important piece of information that should be included in the form is any conditions for which a patient is being treated. While it’s nice to know the medical terminology, describing the condition in your own words is perfectly acceptable. You’ll also want to include a list of any prescription medications that are either being taken currently or over the previous six months. You should be as specific as possible by including the names of drugs taken, dosage amounts and the reason for taking them. All this information can usually be found on either the package or bottle. Non-prescription medications should also be noted on the medical history document. For example, supplements, diet pills, herbs, pain relievers and cough medicines should all be listed if they’re taken with any kind of frequency. If a family member has any known allergies, then this information needs to be written down on the medical history form as well.


A doctor will also find it useful if you include any and all health milestones, including major surgeries, tests or treatments and medical problems. It’s important that you try to compile an accurate list of dates for these events. When putting together this list of health-related milestones, it’s a good idea to touch base with your doctor. Another tip is to update this information whenever you visit a doctor or the emergency room.