Column: “Your health record,” by Dr. Mike Richardson

Maintaining your own health history is very important. Insurance programs change, moves happen, doctors retire, medical needs arise when you are out of town. While you can always have your records transferred, it’s smart to have your own back up set of records for those times when information is needed in a hurry–or when you just didn’t take the time to request records from your previous doctor in a timely fashion.

There are a variety of internet based systems where you can plug in your data and access it as needed. Those require some trust on your part that the information will be held securely, and that you will have the proper device and/or printer to access it when you need it. I like plain old paper. Maybe you’ve got a fancier electronic version to my file cabinet at home. Whatever works for you. The important part is what’s in those files.

The first part is a health history.

1.Keep a list of all of your previous surgeries, ideally including dates and hospital/surgeon. It’s helpful for your future doctors to know what original parts are missing, which have been revised, and where those records are if we need clarification about the events.

2. List all your medical problems, again including dates of onset. Looking primarily for major issues such as hypertension, cholesterol, diabetes, hospitalizations. Things that require ongoing care or may influence how we manage future medical events.

3.An up-to-date list of medications. I am constantly amazed at how many people expect me to know what that “little white pill” that an urgent care doctor gave them is. Most pills are little and white. This list should be on your health record and also in your wallet. Life is unpredictable. You never know when medical care can be needed, and if the emergency room doctor doesn’t know for sure what drugs you are taking they are working partially in the dark.

4. Drug allergies and intolerances. Which drugs are you truly allergic to? (Reactions such as a significant rash, swelling of the lips or tongue, difficulty breathing) Which drugs have enough side effects that you would prefer not to take them again? (Reactions such as nausea, diarrhea, or headache)

5. Habits. Have you ever smoked? If so, how much and how long? Do you drink alcohol? If so, how much and how often? (Be honest here as the response to many medications are influenced by how much alcohol you drink and that would influence what the doctor can or should prescribe for you.) What is your exercise program? That’s a record of what you actually do, not what you want me to believe that you are do- ing. Your degree of aerobic fitness does influence how I might interpret symptoms that you are reporting.

6. A collection of any old reports and letters from your doctor.

The second components are family history and social history.

1. A list of first degree relatives (mom, dad, and siblings), their ages, and health problems that they have experienced. Particularly important are inherited diseases such as hypertension, diabetes, cholesterol disorders, heart disease, and cancer.

2. Your martial status, children and ages (and contact numbers if they are no longer at home), and employment.

3. Your health insurance information, including a copy of your card and information on contacting your insurance company. This is also a good place to keep a copy of any Living Will or Advanced Directives that you have, as well as other legal documents such as Health Care Power of Attorney.

Be prepared and hope to never need the information; kind of like keeping the rain away by carrying your umbrella.

Richardson is a physician at CMC in Mint Hill.

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