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The first time you visit any doctor,
you’ll be asked for your complete medical history. For each illness
or medical problem you’ve had, you should know the diagnosis, date
of diagnosis, symptoms, prescribed medicines and the name
and phone number of the physician who treated you.
In addition to the convenience of having
this information handy, a well-kept medical history helps your doctor better understand how
to treat you.
Sample medical history form
Personal history form
(pdf)
|
Diagnosis |
Date
diagnosed |
Main
symptoms experienced |
Medications that helped |
Special
notes |
Diagnosing physician's name and phone number |
|
Ulcerative colitis |
Aug 1999 |
Bloody diarrhea
|
Asacol
Rowasa, 6-MP |
Developed an allergy to Asacol
|
Dr. Nemo
713-512-2151 |
You’ll also need to provide information about your family’s
medical problems.
Sample family medical history form
Family history form
(pdf)
|
Disease |
Relation of patient to you
(Mother, brother, etc.) |
Date
diagnosed & duration |
Any
curative procedures |
|
Acute hepatitis |
Maternal grandfather |
1960 - 1970 |
Liver transplant, successful |
Once you've found a physician, you may
want a list of useful phone numbers.
Contact list
(pdf)
If you have questions or comments about
this Web site, please e-mail
LifeWithIBD@texaschildrenshospital.org.
 
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