How to summarize your medical history for a specialist

Your family doctor has referred you to a specialist, and the appointment is getting close. The specialist will be seeing you for the first time; the visit is short, but what you need to tell them has built up over years. When was that surgery, how long have you been taking a certain medicine, does anyone in your family have something similar? In this post we walk you through gathering all of it into a one-page medical history summary, step by step.

Why a short summary for a specialist?

Your health information is often scattered: lab results at one hospital, a surgery record at another clinic, prescriptions in a drawer at home. The specialist may not be able to see all of it. Sources that recommend keeping a personal health record point to this same problem: a tidy summary you hold yourself keeps the information in one place.

There is a reason to keep it to one page, too. A long file is hard to read during a visit; a short, ordered page can be scanned in a few minutes. Keep the details with you, and let the summary show what matters most. For general appointment prep, the post 7 notes to take to your doctor's appointment is also useful; this post focuses on a first visit to a specialist.

What goes on a one-page summary?

You can use the headings below in order. If there is something you don't know or aren't sure about, leave it blank or write “not sure”; don't fill it in with a guess.

• Basic details: your name, date of birth, your family doctor's name and someone to contact in an emergency.
• Reason for referral: what brought you to this specialist, in just one or two sentences. If your family doctor wrote a note, bring it.
• Ongoing conditions: diagnoses you have been given and roughly which year they started.
• Past illnesses and surgeries: major illnesses, operations and hospital stays, with the year.
• Medicines and supplements: the name of every medicine and supplement you take, how to take it as written on the prescription, and since when.
• Allergies: drug, food or other allergies and what kind of reaction you had.
• Recent tests: the name and date of your latest blood test or scan; keep the results themselves in a separate file.
• Family history: significant conditions in close relatives.

Rather than copying lab results into the summary, it is more practical to store them somewhere organized. For that, see 6 ways to keep your lab test results organized.

Turning your symptom into a timeline

One of the things a specialist most wants to know is how your symptom started and how it has changed. Writing this down in order is much easier than trying to remember it during the visit.

1. Write down the start. When did the symptom first begin? If you don't know the exact date, the month or season is enough.
2. List the changes. Did it get worse, ease off, or come and go? Add clear turning points with their dates.
3. Add what you have tried. Which doctors have you seen so far, which tests were done, which treatments were tried, and what happened afterwards?
4. Sum up today. What is hardest for you right now? How does it affect your daily life?

A short example might look like this: “In March I started getting occasional pain in my right knee. In May it became more frequent when going down stairs. In June I saw my family doctor, had an X-ray and was referred to this specialist. Right now I struggle after long walks.” Four sentences tell the specialist the story of your symptom in seconds.

Keep this section to a few lines. If you have longer notes, keep them on a separate page and show them if the doctor asks. Don't try to interpret your symptoms or diagnose yourself; writing down what you are experiencing, as it is, is enough. Assessing it is your doctor's job, along with the examination and tests.

While putting the timeline together, old prescriptions, hospital discharge papers or appointment emails can help you recall dates. If you can't find an exact date, writing “around” is fine; getting the order right matters more than the exact date.

Gathering your family health history

Close relatives share genes, the places they live and some habits. That is why family history can play an important part in a specialist's assessment. A condition running in your family does not mean you will have it too; leave the interpretation to your doctor and simply gather the information.

• Start with your parents, siblings and children; if you can, add grandparents, aunts and uncles.
• For each person, write down significant conditions and, if known, roughly the age they started.
• You can ask older relatives about things you don't know; mark anything nobody is sure of as “not sure”.

Tidying up the summary and taking it to the appointment

Once the summary is ready, a few small steps make it more useful. Write the questions you want to ask the doctor on the back of the page. Before the appointment, ask your family doctor or clinic which documents and reports need to be sent to the specialist; this can sometimes take time.

To avoid forgetting what was said at the appointment, jot down short notes right after the visit. You can use the method in 5 steps to organize your notes after a doctor's appointment. If you want to make any change to your medicines, don't do it on your own; talk to your doctor or pharmacist first. If your symptoms suddenly get much worse while you wait for the appointment, call your local emergency number without waiting.

Keeping records for your summary in Oveluni

In Oveluni, you can save your specialist appointment with Add appointment and set a reminder; the appointment shows up in the Calendar alongside your other records. With New medication plan you can add the medicines you take, and you can write daily observations about your symptom with A note in the Quick add menu. Oveluni has no area for storing lab results; you can add the test name and date as a note.

Before the appointment, the PDF report lets you gather the last 7, 30 or 90 days, or a range you choose, with the categories you want, into one file and preview it. Your notes are not included in the report by default; to add them, turn on the Include notes option. For details, see the guide creating an Oveluni PDF report and sharing it with your doctor. Oveluni reflects your records; it does not diagnose. Oveluni is coming soon to the App Store.

Sources

1. MedlinePlus: Personal health records
2. MedlinePlus: Family history
3. MedlinePlus: Talking with your doctor