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PERSONAL MEDICAL HISTORY Insurance history by benbenzhou


									                                               “Jump Drive” for Better Health Care

A ―jump drive‖: also known as a USB drive or flash drive is a ―plug-and-play‖ portable storage device that is lightweight enough to
attach to a key chain and can carry ALL your medical records including x-rays and cat scans.

Dr. Wells states: ―jump drives empower us in our health care and enable patients to be there own advocates. Medical information &
records can be stored on a ―jump drive‖ and is important to someone with a chronic disease for doctor visits, emergency room visits,
and vacation travel – to name a few. Below find detailed medical information that can be included on your personal ―jump drive‖.
Please note that general information is better than none, so we have attached a basic template that you can download to your ―jump
drive‖ and make it as detailed or simple as you feel necessary

                                                PERSONAL MEDICAL HISTORY

Name:                                                                                    Phone #:
DOB:                                                                                     Address:

Date Information Last Updated: (can be updated weekly or as medications change)

Personal Insurance Information: (include name, address, phone, and policy number)
Medical Record Number at known hospitals:

Emergency Contact(s):
        Relationship to Patient:
        Phone Number(s):

           Relationship to Patient:
           Phone Number(s):

If I am unable to consent to treatment, then contact _____________@ ___________ to obtain consent.

Primary Care Physician/CF Center Contact Information:

           Phone Number(s):                                        Fax:

Specialty Physician Contact Information: (include specialists for liver, gastro, etc.)

           Phone Number(s):                                        Fax:
           Reason followed by this doctor:


           Phone Number(s):                                        Fax:
           Reason followed by this doctor:

BIRTH HISTORY: (mainly important for infants)

 Hospital Name:
 Hospital Course (include length of stay, treatment, NICU course if applicable):

 Estimated Gestational Age (i.e. full term):
 Vaginal Birth or C-Section

  Age of Diagnosis:
  Mutations (if known):
  Sweat Test results/date:

     1.  Have you ever had hemoptysis (aka coughed up blood)? If so, when? What was the therapy instituted?
     2.  Include most recent pulmonary function tests.
     3.  Do you have a history of failure to thrive? Malabsorption? Pancreatic Insufficiency? GI Obstruction?
     4.  Have you ever had a collapsed lung (aka pneumothorax)? If so, then include how you were treated.
     5.  Have you ever had a CT scan of the chest? Or any body part?
     6.  Include copy of most recent Chest CT, Chest X-Ray---include date of all studies.
     7.  Have you ever been intubated?
     8.  Have you been diagnosed with CF-related diabetes mellitus?
     9.  Have you ever seen a specialist for your heart? Liver? Had impaired Kidney Function? Do you require renal-dosing of
     10. Have you been evaluated for transplant? Are you on a transplant list—if so, then include contact information of center?


 Reason for           Duration of          Treatment                      Hospital/Doctor Name
 Admission                   Stay                         Given                    Contact information


Include history of PICC lines, medi-port placement and dates if possible—and, any/all surgeries.

ALLERGIES/ADVERSE EFFECTS (list what adverse effect was-- e.g. hives, difficulty breathing)

CURRENT MEDICATIONS (include name, dosages & routes of administration)

MICROBIOLOGY: Include here the names of the bugs/bacteria you have grown in the past in blood/CSF/urine and, most
importantly, sputum, their susceptibility pattern (and the antibiotics they are resistant to), dates sputum cultured--- if possible. Have
you grown MRSA (methicillin-resistant staphylococcus aureus), ABPA (allergic bronchopulmonary aspergillosis), B-cepacia etc…?
(can obtain copy from physician)

IMMUNIZATION RECORD: (can obtain record from physician)

LABORATORY INFORMATION: Include most recent lab results with dates. Include Blood Type if known, Urine for Creatinine
Clearance, IgE levels, Hemoglobin A1C levels and so on... You can ask for a copy of your most recent lab results and scan them in to
this document---old ones as well.

In this section, if possible, scan in or download most recent/any chest x-ray, CT Scan, EKG, abdominal film, bronchoscopy (etc..) and
the report/reading. If cannot obtain this, then just include copy of report.

Include history of smoking, drinking, illicit drug use and/or sexual activity. In school? Working—job type? Disabled? With whom
do you live and what kind of environment? Pets?

Include pertinent family history of medical illness from both sides of family and relation of individual affected---e.g. heart disease,
stroke, lupus, psychiatric illness, sudden death, genetic syndrome…
REVIEW OF BODY SYSTEMS (include here any systems that have been affected in your life and what the treatment plan being
instituted is/was, frequency of appointments, specifics) Ask yourself these questions and include the answers in this section or ―Past
Medical History‖ for completeness.

           Pulmonary: Include here frequency of appointments (as with all sections). Therapy regimen for chest physical therapy.
                   Have you ever been on steroids? Number of times? When was last bronchoscopy—what was the report??
                   Ever intubated? What is your daily supplemental oxygen requirement?

           Cardiology: Include here any cardiac/heart issues. Have you ever had an             echocardiogram and why? Blood
                    Pressure problems? Heart failure? Heart Attack?

           GI/Fluids/Electrolytes/Nutrition: What are your dietary restrictions? How long have you required enzymes? Any
                     known Vitamin/Mineral Deficiency?
                     Have you had problems with constipation/blockage? Liver disease? Gallbladder Disease? Fatty, foul-
                     smelling stools? Ever been on IV fluids for severe dehydration? Ever been on TPN & why? Ever had a
                     Gastrostomy tube? If so, are you on overnight feeds and what are they (include feed name, amount and rate

           Hematology/Oncology: Have you ever had problems with forming clots? Or prolonged bleeding? Do you take Vitamin
                    K? Ever had a blood transfusion- when, how many? Any hemoptysis—coughing up blood? Chronic Anemia?

           Endocrine: Have you been diagnosed with CF-related Diabetes? Are you on insulin? Normal Menses?

           OB/Gyn: Any issues? Had any children?

           Genitourinary (GU): History of Infertility? History of Kidney disease/failure? Any known kidney toxicity from
                     antibiotic treatment?

           Neurology: Any issues? Any hearing loss from Antibiotics? Vision problems? Headaches/Migraines?

           Allergy/Immunology: Have you ever needed to be sensitized to an antibiotic? Have any known immunodeficiency?

           Ear/Nose/Throat: Nasal Polyps? Chronic Sinusitis?

           Infectious Disease: Should include in microbiology section all bugs grown in past. Any adverse reactions to

           Orthopedics: Any spinal deformities? Osteopenia/Osteoporosis? Fractures?

           Psychiatry: History of Anxiety/Depression

           Dermatology: Skin disorders?

           Genetics: What are your mutations? (ie: delta 508). Family History of medical problems on both sides of family.

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