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Craig G. Hurwitz, M.D.

Health tracker

The Diagnosis/Problem Sheet: A quick index to your medical history

The diagnosis/problem sheet will serve as a valuable and quick summary of your medical history. It is a sheet well worth the effort needed to prepare it. By keeping your own diagnosis/problem sheet, you will benefit by having this sheet available to every doctor you see.

In addition to its value as a medical summary, it can remind your doctor what type of follow up you need. For example, let us say you had thyroid surgery ten years ago. Following thyroid surgery therre is a very high incidence of an underactive thyroid gland. The symptoms of an underactive thyroid gland can be very low grade until the condition worsens. By performing a yearly thyroid lab screening your doctor can pick up any developing condition early. A diagnosis/problem sheet helps ensure that the testing is not overlooked.

Get Started

A good way to begin is just to list all the significant health issues and illnesses you have had. Include operations and any procedures or treatments you have had. Write down approximate dates. Do not list common self limited conditions such as colds or a single episode of pain. A simple chronoligical list is better than no list at all. You could also group similar problems together such as multiple heart attackes, heart catheterizations or bypass surgery all listed under a heading of coronary artery disease. Below is an example.

Hypertension

Onset 1984

Type II Diabetes

  • Started insulin in 2004
  • diabetic retinopathy (laser Rx left eye 2011

Onset 1998

High Cholesterol

2005

Coronary artery disease

  • heart attack in 1998
  • heart attack in 2003 - had heart cath in Burlington VT - 2 stents (Dr. Smith)
  • 3 vessel heart bypass surgery in Burlington VT (April 2009)

 

Other surgeries:

  • appendix removed (1955)
  • Gallbladder removed (1994
  • Tonsils out at age 12
  • left groin hernia repair 1998

 

Hypothyroid (on medication)

2004

 

Do the best you can setting up this sheet. It is a working sheet and should be udpated periodically. It does not have to be perfect. Remember that it is an ongoing process to reflect what you consider most important about your developing medical history.

You now have a very quick index to your medical history. Bring a copy with you when you visit any doctor and have a copy available when you travel.

In my medical practice, where I follow many patients throughout the years and some with very extensive medical records, I rely on an accurate and careful diagnosis-problem sheet. It is a very simple yet extremely important part of optimizing your health care delivery.

 

Your Personal Medical Record: Helping Your Doctor Help You

  1. Your diagnosis/problem sheet

  2. Your medication/allergy sheet

  3. Your immunization sheet

  4. Family history, social history and occupational history

  5. Tracking your symptoms before an office visit and the health diary