A medical history can be a crucial tool for helping physicians diagnose conditions, recommend testing procedures and treat health ailments. Each time a patient seeks medical attention, the healthcare provider is likely to begin by reviewing and updating the patient’s medical history, which includes the following:

• Personal medical history. This consists of current symptoms, chronic conditions and medications, as well as past history of surgeries, allergies, hospitalizations and other information.
  
  
• Social history. This includes information about patient habits and lifestyle (e.g., occupation, diet, exercise, tobacco and alcohol use).
  
  
• Family history. This portion deals with information about any health problems that may run in the family. Many conditions (e.g., alcoholism, allergies) are believed to result, in part, from genetic factors.

A physician will obtain this information by asking a series of personal questions. Patients should answer to the best of their ability, without concern for potential embarrassment and without guessing. Physicians use those answers to identify patterns of symptoms that are suggestive of a single condition. They may ask additional questions to better understand symptoms and further identify current health issues. By law, medical histories are not shared with anyone outside the physician’s office without the patient’s permission.

Creating and maintaining an accurate medical history with each healthcare provider is the first step in achieving quality health care. It is equally important to keep copies of these records at home in a safe, yet accessible location.

After the medical history is complete, a physical examination will follow. Depending on the information revealed, the physician may determine what, if any, additional testing is needed.

A medical history provides a comprehensive record of health information, including illnesses, conditions, surgeries, hospitalizations and allergies. This information is often the key factor in making a proper diagnosis and therapeutic decisions.

The reliability of a medical history is crucial because medical decisions are made on the behalf of the patient based on this information. At times, however, medical history information may not be entirely accurate. Ambiguities and even omissions are common mistakes that patients make in maintaining accurate medical histories. Omitting information can adversely affect care.

In some cases, embarrassment or fear of judgment may prevent a patient from mentioning a concern about certain medical problems, such as a sexually transmitted disease, chronic alcohol use or a history of depression. This can also apply to children, who may be ashamed of bedwetting or other conditions. However, the results of these omissions can result in serious consequences and a reduced level of medical care.

It is estimated that tens of thousands of deaths each year are attributed to medical errors. It is unknown how many of these could be prevented through more accurate medical histories. But comprehensive and accurate information regarding allergies, prescriptions or past medical conditions may be one way, at least in some measure, of reducing those numbers.

A common assumption is that it is sufficient for only physicians to maintain medical records. However, patients may also maintain copies of medical records to improve their quality of care.

Without this information to refer to, medical histories taken for a specific event may be less accurate. For instance, when asked to give a medical history just prior to a surgical procedure, the patient’s memory may be affected by anxiety or pressure regarding the upcoming surgery. Having documents to refer to can ensure a complete medical history will be provided even in such stressful situations.

A personal medical history is information about the current problem (chief complaint) that prompted medical attention, as well as your history of illnesses, surgeries, allergies and other relevant information. The physician will begin to assess the patient’s present condition by asking questions about the particular symptoms or event that prompted them to seek medical care. For example, the physician will ask the patient to describe the location, nature, severity and duration of symptoms such as skin rash, chest pain, wheezing or fatigue.

Patients often find it helpful to write down symptoms beforehand and read them to the physician. It is easy to forget important details during a medical encounter, especially on a first visit.

After hearing these vital clues during the initial visit, the physician may ask some follow–up questions that may take about 20 to 30 minutes. The physician may also conduct a review of systems, which is a “laundry list” of symptoms related to various organ systems in the body. These questions are designed to discover additional information that the patient may have forgotten to tell to the physician.

It is important for physicians to have access to such personal information as:

• Chief complaint. Includes physical symptoms that the patient is currently experiencing and the context in which they occur.
  
  
• Current or past illnesses or conditions. Any health problem that the patient has had in the past or may have now.
  
  
• Past injuries and physical problems. Any injuries (e.g., concussions, sprains, bone fractures) or physical problems (e.g., fainting, dizziness, fatigue) that have previously occurred.
  
  
• Allergies. All known allergies, including medications, foods and materials.
  
  
• Current medications. All medications currently being taken, both prescription and over–the–counter, including vitamins and herbal supplements. Doses and dosing schedules are also important.
  
  
• Hospitalizations and operations. A list of all dates and reasons why the patient been hospitalized, and a list of all dates and types of surgeries the patient has undergone.
  
  
• Immunizations. Updated record of all immunizations. This is especially important for children.
  
  
• Height and weight. The patient’s approximate height and weight may be used in calculating medication doses.
  
  
• Previous healthcare provider contact information. Names, addresses and telephone numbers of previous healthcare providers and permission to access the patient's medical records allow the new physician to review past care.
  
  

For women, a visit to the gynecologist will involve a complete medical history, but the physician will focus primarily on your gynecological history. Depending on age, the physician may ask about the patient’s menstrual history (e.g., age at onset of menstruation, average length of periods and regularity of periods) or the arrival of menopause. Other topics may include current or past methods of birth control, uterine abnormalities or fertility problems.

All women who are pregnant will be asked to provide their physician with an obstetrical personal history. This will include questions on previous pregnancies, their outcome (such as birth dates, gender and weight) and any complications.

The patient will be asked about their social history, which includes information about lifestyle and habits, such as:

• Diet
  
• Exercise
  
• Tobacco use
  
• Alcohol use
  
• Occupation
  
• Sexual habits
  
• Family structure
  
  

A social history can have a significant impact on a patient’s health. For instance, if exposed to harsh chemicals while at work, a patient may experience contact dermatitis. In contrast, skin rashes may be the result of foods in a person’s diet.

Information on the lifestyle and habits of a parent or spouse may also be obtained, as this information may assist with diagnosis. Exposure to secondhand smoke, for example, can raise the risk for numerous respiratory conditions, including asthma and lung cancer.

A family medical history provides detailed information about the present and past health of the patient’s family members. A family medical history can greatly increase (or decrease) the risk of developing certain medical conditions.

Most Americans believe that having a thorough and accurate family medical history is important. In fact, according to the U.S. Centers for Disease Control and Prevention (CDC), 96 percent of Americans believe that knowing family history is important to their health. Surprisingly, the same CDC survey revealed that only about one–third of Americans have ever tried to gather and organize their family’s health histories.

Many patients keep track of their family medical history by creating a medical family tree. It is often helpful to bring a medical family tree to an initial physician visit. A complete family tree traces medical history through at least several generations, including parents, grandparents, brothers, sisters, half brothers and sisters, aunts, uncles, nieces, nephews, children and grandchildren. Patients should also include their spouse’s family history if they are married and/or have children.

For each relative include such information as:

• Racial and ethnic background.
  
  
• Age.
  
  
• Any known congenital (existing at birth) or hereditary disorders.
  
  
• Major illnesses or conditions, the approximate dates when they were diagnosed, age at diagnosis, and which organs were affected (if applicable). These include:
  
  
  • Migraines
    
  • Arthritis
    
  • Heart disease
  • High blood pressure
  • High cholesterol
  • Stroke
  • Cancer
  • Alzheimer’s disease
  • Down syndrome
  • Birth defects
  • Mental retardation
  • Asthma and other chronic respiratory disorders (e.g., COPD)
  • Osteoporosis
  • Cystic fibrosis
  • Sickle cell anemia
  • Diabetes
  • Eye diseases
  • Vision loss
  • Hearing loss
  • Depression and other mental illnesses
    
    
• Chronic ailments or risk factors (such as smoking, obesity or alcohol problems).
  
  
• The cause of death and age at the time of death of deceased relatives.
  
  
• Childhood illnesses, vaccinations, surgeries and treatments.
  
  
• Histories of infertility, miscarriages, stillbirths or sudden infant death.
  
  
• Pregnant women will be asked to provide an obstetrical family history (e.g., twins, genetic problems), including any predisposed conditions.

If the patient does not have enough information about their parents or grandparents, it is possible to track down much of the information through public records. For instance, a great deal of information can be obtained through death certificates from state health departments. There are sometimes fees for these records, but they are usually under $10 and will include an age and cause of death. Obituaries can also be good sources of information.

A medical family tree serves numerous purposes. It can:

• Help identify seemingly healthy people who may be at an increased risk of developing a certain disease (e.g., heart disease) in the future.
  
  
• Help the physician create screening schedules and management protocols (e.g. x-rays, ultrasounds, magnetic resonance imaging) that may detect some hereditary conditions earlier.
  
  
• Help the physician implement prevention strategies that may delay or possibly prevent some hereditary diseases from ever developing.
  
  
• Help the physician decide which tests are necessary for diagnosis of hereditary conditions.
  
  
• Help a physician determine which members of the family may be at risk for developing certain diseases.
  
  
• Provide information about the risk of passing on a susceptibility to certain conditions to children (e.g., hereditary cancers).
  
  

The patient should notify their physician of all medical information. Even illnesses that do not seem important to the patient may ultimately allow a physician to make a more accurate diagnosis or to begin screening for certain conditions as soon as possible.

Patients should never try to guess their family history. Though it is important to gather a complete picture with as much accurate information as possible, it is just as important to not speculate on any blanks that might be left. A thorough family medical history can go a long way towards preserving health, prolonging life and reducing the risk of developing familial illnesses. However, an incorrect family health portrait may be much worse than an incomplete family health portrait.

There are several steps a patient can take to create a more precise medical history and, in turn, improve the quality of health care for themselves and their family. These include:

• Ask that medical forms be provided before an office visit to allow more time for accurate answers.
  
  
• Maintain an up-to-date list of all medications (past and present); including the drug name, purpose, dose and instructions, as well as the physician who prescribed it and the date it was prescribed. Include all herbal, alternative or over-the-counter medications, as well as alcohol and illegal drugs.
  
  
• List any allergies to drugs, foods, insects and others.
  
  
• List information needed in the event of an emergency separately so that it will be easy to locate quickly.
  
  
• Maintain a list of major diseases in the family, including heart disease, stroke, cancer or diabetes. Also include any genetic conditions, such as blood disorders, which can be passed on to future generations.
  
  
• Keep records of immunizations, major illness and injuries, major surgical procedures or hospitalizations, other important test results, eye records and dental records.
  
  
• Maintain a list of the names, addresses and telephone numbers of all physicians seen over the past several years.
  
  
• Request a copy of medical records from all healthcare providers.
  
  
• Have copies of living wills, organ donor authorization and advance directives, such as a medical power of attorney.
  
  
• Keep copies of health insurance information.
  
  
• Provide important information to babysitters and childcare administrators. This information should include parent phone numbers and the physician’s name and phone number.
  
  
• Information about special needs children. Parents should include any pertinent information about a special needs child in their medical history forms.
  
  
• For women, be sure to maintain a history of childbirth, including miscarriages, abortions, Caesarean sections and natural deliveries.
  
  

With advanced technology, there are several companies that will store medical histories in accounts online. This option offers individuals the advantage of having all of their information in one safe place. In addition, it allows for easy access and the ability to update their records on a continual basis.

Preparing questions in advance can help you have more meaningful discussions with your physicians regarding your conditions. You may wish to ask your doctor the following questions related to medical histories:

1. What relatives should I include as part of my family medical history?
   
   
2. What information should be noted in my family medical history?
   
   
3. What is the best way to document my family medical history?
   
   
4. Many of my relatives are deceased. How can I learn more about my family’s medical information?
   
   
5. Is it okay for me to make guesses in order to fill in missing information in my family medical history?
   
   
6. Who has access to my medical history records?
   
   
7. Does my medical history suggest a risk for any diseases?
   
   
8. Now that you have collected my medical history, what is the next step?
   
   
9. Are there lifestyle changes I can make based on my family history and other risk factors that will help prevent a hereditary disease?
   
   
10. Can you recommend any companies that gather and store medical histories?