How To Present Medical History
- 1). Provide the physician with the patient's general information such as name, sex, age, marital status and occupation. Make sure to note any hazardous working conditions that the patient works around that may be associated with any medical issues they're experiencing.
- 2). List any medications the patient is currently taking and any current medical conditions they are being treated for, such as the patient being on thyroid medication after being diagnosed with hypothyroidism one year ago. You would list anything, including medications, such as blood pressure medications for symptoms of hypertension, even if they were diagnosed six months or six years ago.
- 3). List any allergies the patient may have to any medications, dyes or contrasts. Listing patient allergies accurately can ensure that the physician is aware of any possible allergic reactions the patient may have to certain drugs.
- 4). List any past medical procedures or surgeries. Past medical surgeries can assist a physician in understanding a patient's overall medical condition, as well as any chronic conditions they may have.
- 5). Describe to the physician the patient's current medical issues at hand, as well as a summary of the overall medical conditions of the patient. For instance, "Patient is complaining of unsteadiness and dizziness, but has recently had changes in many of her medications," or "Patient states the dizziness is more noticeable on abruptly arising from sitting or lying position."
- 6). Describe any social history the patient may have, like if the patient is a smoker or social drinker. Social history such as smoking can have a significant negative effect on many health conditions such as breathing problems.
- 7). Provide the physician with any test results or reports the patient may have of any past medical tests they have had conducted. The test results can help the physician properly assess the best treatment options and any further testing that may be required for properly diagnosing the patient. Make sure you point out any past test results that may have been missed or require further workup.