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For doctor visits, it’s wise to bring a complete record of your medical history

  • Special to The Washington Post
  • Published Monday, Oct. 29, 2012, at 11:23 p.m.

Usually I go into a doctor’s appointment armed with a million questions, but I’ve never thought too deeply in advance about what information the medical professionals might need from me.

That’s unfortunate, because coming to any provider equipped with at least some background knowledge about your medical history can help you get better, more personalized and targeted care, says primary-care internist Foster Montalbano of Springfield Family Medicine in Alexandria, Va.

“In our society today, you have to realize that the only person who is truly invested in your health, besides your mother, is you,” he laughs, before getting down to serious business: “Given the fact that a lot of people today don’t (have or keep up) with a primary-care provider whose job is to keep track of basic vitals like blood pressure, weight and body mass index, as well as other key information … it is incumbent on the patient to know these things and to have them at the ready when needed.”

Family physician Vincent WinklerPrins, an associate professor of family medicine at Georgetown University Medical Center, suggests that everyone keep a portable, personal health record of some sort — paper works fine, though there are online and flash drive options as well.

So, what specific information should you chronicle and keep up to date?

•  Immunization status. Most parents are keenly aware of the importance of documenting their children’s vaccinations for school entry, sports clearance and the like, but how about your own shot record?

“The last time adults think about immunizations is generally when they go off to college, but (they) may not be aware that things need updating or that there are new vaccines they should consider,” depending on such factors as age, health status and travel plans, says WinklerPrins. For example, he notes, it’s important once a decade to get a tetanus booster. That shot is now typically combined with a vaccine against pertussis, or whooping cough, which has been on the rise in recent years.

•  Drug allergies. It’s important to know not only what medications you’re allergic to but also what your exact reaction to each offender is.

“Do you get a bad rash, have breathing difficulties, serious abdominal pain or a loss of blood pressure? Did you have to go to the emergency room, or was it just an intolerance to a drug — like it made your stomach upset and you threw up?” says WinklerPrins. “The more specific you can be, the better.”

•  Name and dosage of current medications. This includes a vigilant recounting of all of the over-the-counter drugs you’re taking, as well as any vitamins or supplements.

“We need to know precisely what you’re taking, because many medications may have drug interactions … and side effects can run people into trouble,” says WinklerPrins. Montalbano points out that there’s more to know than just how much of a drug you’re taking, such as the full range of its potential side effects and proper storage instructions. “There’s no excuse for patients not to empower themselves, because every prescription you pick up from the pharmacy has a three-to-four-page handout that’s chock-full of information,” he says. “The more you know, the easier it is to have a conversation with your doctor about any issues or problems that come up.”

•  Prior surgeries and conditions. You’d be surprised how many people can’t recall whether they had their appendix out as a child and similar key facts, says WinklerPrins.

“These days, so many people have had laparoscopic surgery, and sometimes you can barely tell if they’ve had an operation (just by looking at them),” he adds, noting that not only is the type of procedure you had done important, but also when, since surgical procedures have changed over time. “Whatever it is — a partial hysterectomy, a vasectomy, a breast lump removed — even a little bit more detail, so we know exactly what part was removed and what the findings were, is helpful.”

•  Family history. Keeping close track of your parents’ and siblings’ medical problems (including age of onset) is extremely useful, along with causes and ages of death, says WinklerPrins. He stresses that medical professionals are particularly interested in any premature deaths — meaning before age 55 for men and age 65 for women. “A well-documented family history can often … help us by homing in on what’s relevant and determining when we screen for certain things,” he explains. Bear in mind, says Montalbano, that “family history does not predict the future health of that person, but it provides an assessment of risk to that patient.”

Beyond this, Montalbano recommends that those who have chronic conditions — migraines, rashes, sleep disorders, depression, any pain syndrome or even a persistent cough — keep a comprehensive log of the frequency and intensity of their symptoms.

“There are a lot of cases where people come to me and I will run a workup but nothing shows up,” he says. “What I have to fall back on is the realization that the test that we have is not sensitive enough to pick up on this malady, and often the only way to get to the bottom of it is with the patient’s symptom diary.” A detailed journal can help you understand that you seem to get blinding headaches about twice a month, and often when the weather is humid, which Montalbano says is much more useful in the diagnosis and treatment process than simply reporting that you get them “frequently” or “every so often.”

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