DIY Med Hx

The do-it-yourself (DIY) medical history.   Use these headings and keep an up-to-date copy for new doctors, specialists, emergency room or hospitals.  Use a word-processor or Google Documents to create and store your medical history.

  • Identifying information:  Name, Date of Birth, Address, Phone number

  • Past Medical History:

    1. various diagnoses with dates of any hospitalizations and causes

    2. recent blood tests, x-rays or other tests with results (or attach report)

  • Past Surgical History: name of surgeries with date, surgeon, and hospital

  • Childhood illnesses:  birth defects or serious illnesses when a child

  • Obstetrical History (women):  pregnancies and outcome, number of children

  • Psychiatric History:  depression problems etc. and list of hospitalizations

  • Family Medical History: just parents, siblings and children

  • Social History:

    1. where you live, with whom, occupation, when retired etc.

    2. habits including smoking and alcohol consumption

    3. advance directives (living will, 5 wishes etc.)

  • Medications:

    1. drug names, strength, how often taken, for what

    2. pharmacies with phone and fax numbers

    3. Drug Allergies

    4. Drug Intolerances or side-effects, what drug and when it happened

    5. Food or Inhalant allergies

  • Immunizations:  which vaccines and when

  • List of current health care providers:  primary care, pediatrician, ob/gyn, and specialists

  • Prefered hospital in case hospitalization needed

  • Emergency contacts:  names, relationship and phone numbers


The following link is to a detailed self-history form that you might find at a health care provider’s office.  You might get some ideas for your own history.  Self-History Form.

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