Personal Medical History Record

Who this is for

Your own history on one page. It holds the conditions you list, the medicines you take, the allergies you have been told about, the operations and admissions behind you and any family history you choose to note — so that somebody who has never met you can read it in a few minutes.

Anyone who sees more than one clinic, people moving practice or moving country, carers and relatives holding the paperwork for someone else, and anybody who has ever been asked for their history at a desk and answered from memory.

What this helps you track

• Conditions and diagnoses in your own words, with the date each was first noted
• The medicines you are taking now, copied from the labels
• Operations, procedures and admissions with dates and the hospital
• Allergies and reactions you have been told to mention
• Family history you have decided is worth writing down

How to use it

1. Fill in the identifying details at the top: name, date of birth, the patient or health service number your records carry, your practice and who to contact for you.
2. List your conditions as you would say them out loud, with the date each was first noted and who looks after it.
3. Copy your current medicines straight from the labels, word for word, including the strength and directions printed there.
4. Add past operations and admissions with their dates — approximate years are better than blanks.
5. Write in only the family history you want on the page; it is yours and nobody else needs it.
6. Keep the paper copy with your documents and take it to appointments, or fill it in online and save it in your own browser.

Formats

• Printable PDF (A4 and US Letter)
• Fillable PDF with form fields
• Fill in online, saved in your browser

The printable is laid out inside a box that fits both A4 and US Letter, so the two files are identical and neither one is scaled. The fillable PDF has real form fields. The online version keeps what you enter in your own browser and builds the completed PDF on your device.

How to print

Download the A4 or US Letter file to match the paper in your printer, open it in a PDF reader and print at 100% — not "fit to page", which shrinks the writing space. Both files leave a 14 mm margin, which clears the unprintable edge on home printers. To print the online version with your entries in it, use the Print this sheet button, which prints only the sheet and none of the page around it. More on printing.

Questions

Is this an official medical record?

No. Your official record is held by your practice and the hospitals you have attended. This is the copy you keep, written by you, to carry with you and to read from when somebody asks what you have had and what you take.

Does the sheet tell me anything about my conditions or medicines?

It does not. There is no dose, no interval, no range and no explanation of any treatment anywhere on it. Every entry is one you write down from what you were told by the person who told you.

What if I cannot remember a date?

Write the year, or the month and year, and mark it approximate. A record that says an operation happened around 2014 is far more use to a clinician than one that leaves the line empty.

Should I really write down family history?

Only if you want to. Some people are asked about it often and find it easier to have a line ready; others would rather not. The table is optional and can be left blank or crossed through.

Can I use one sheet for the whole household?

One sheet per person. Histories are individual, and a sheet that mixes two people is the kind of thing that gets misread at exactly the wrong moment.