Medical History Form

danemayer

Well-known member
As we've aged and medical procedures, surgeries, prescriptions, etc. have begun to become more numerous, and harder to remember, we've been keeping printed Medical Histories. These have proven extremely useful when going to an Emergency Room as it provides most of what the Doctors and Nurses need to capture our history. The nurse always makes a copy to attach to our chart.

At the South Texas Chapter Rally last week, the subject of Emergency Info came up and I thought it might be helpful to share the form we've been using.

I've made up a PDF fill-in-the-blanks Form which is attached. Save the document to your computer, open it and follow the instructions on page 1.

I'd suggest keeping a copy in your Tow Vehicle and if possible, on your person. One for you. A separate form for your spouse.

I hope this is helpful.
 

Attachments

  • Medical_History_Template.pdf
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rick_debbie_gallant

Well-known member
Well done on the list! What do you think about including a few more things:

Blood type
next of kin information
contact info of persons traveling with them
health insurance information

just a few more ideas. again great job. Thanks for putting this together.
 

danemayer

Well-known member
Well done on the list! What do you think about including a few more things:

Blood type
next of kin information
contact info of persons traveling with them
health insurance information

just a few more ideas. again great job. Thanks for putting this together.

I'm working on a glovebox kit; an extension of the Alabama Yellow Dot program.

This is the 1st form with several more to follow. There'll be a separate form for emergency contacts. Another for Dependents/Pets info, which will include itinerary info so your rig can be located. Another to list insurance policy numbers and phone contacts.

Other info that might go into the kit would include copies of your medical insurance cards, auto/RV insurance cards or declarations, Advance Medical Directives, Powers of Attorney. These would be documents you'd have to make copies of to put in the kit folder.

As to Blood Type, you could write it on the form by hand. If there are any EMTs on the forum, maybe they could weigh in on whether medical personnel would prefer to run their own test to determine blood type, or take it off a piece of paper you're carrying.

I have static cling window decals on the side truck windows to alert emergency personnel to the folder in the glovebox. If you like, you can order yourself a set of 2 for about $8 by using this link.

Walmart has 6x9" clasp envelopes (6 for about $1). If you order the decals, download a copy of the artwork attached below, print it, and glue or tape it to the envelope that goes in the glovebox. Then just keep the docs current.
YellowStickerFolder.jpg
 
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danemayer

Well-known member
I've put together the additional forms:
- Children and Pets
- Emergency Contacts
- Insurance
- Travel Itinerary
- Medical History
The templates and image files for the folder and the decal are all downloadable at this link:



Again, if you want to order 2 decals for about $8, you can use this link

These forms can be printed on your printer and filled out by hand, or you can fill in the blanks and print out the completed forms. It'll be easier to maintain and easier to read if you fill in the blanks.

You can get 6 6"x9" Clasp Envelopes from Walmart for about $1.
 
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Tom_Diane

Member
I made a chart pretty similar after a miserable try at explaining to a traveling Er Pulmonary Dr the sequnce of events in my life starting at Stage 4 colon cancer to the Diabeties dx to the Wegeners Vasculitus dx and all that the damage it caused and then they ordered Lasix and kept me 6 days and released me ofnly to return because they over loaded the lasix and my potassium level both dropped. I was home one day and had to be readmitted worse than I was the week before, with pneumonia. This after I told the nurse I take the Lasix only as needed for the water retention from my kidney disease and to my knowledge had nothing to do with my COPD. Good idea to have a chart like you did but I filled a whole page with my info on each subject,Meds I take reach 26 pills a day. It also included family history of Diabetes and cancer etc. I wouldnt be with out a chart like you gave, thanks
 

mobilcastle

Well-known member
It is an excellent idea. My DW started doing this some years ago as it seems every other time you go to your regular doctor they want a new form filled out.
 

jmgratz

Original Owners Club Member
I bought a flashdrive with a program that keeps all of your medical information on it. You can take it with you and then give it to your doctor and/or hospital and they can put it in their computer and see all of your medical information. They sell them at RV shows. Got to admit that I have not been good at keeping it current though.
 

gasman

Camp Socializer
Hey Dan, we really like this idea and in fact got the kits from you in Gillette. What if you either added a space for the current date or set it up to date stamp it when the form is printed. The medical professionals would know how current the info without having to guess how old the paper is. Some of us may not be as diligent as we should be in keeping the info current.
 

danemayer

Well-known member
Hey Dan, we really like this idea and in fact got the kits from you in Gillette. What if you either added a space for the current date or set it up to date stamp it when the form is printed. The medical professionals would know how current the info without having to guess how old the paper is. Some of us may not be as diligent as we should be in keeping the info current.

The form has a field at the top right titled "Date last updated". After typing your name, the tab key will take you to that field next.

I notice that opening the file from Tapatalk on my iPad, the field title doesn't show for some reason.


Sent from my iPad using Tapatalk HD
 

JanAndBill

Well-known member
Dan the "Yellow Dot" program is not limited to just Alabama, at present I believe there are about 22 states which offer the free packets. Here in our state the County Sheriff's Office has the packets available, I am assuming that other states would be similiar. As a Volunteer Fire & First Responder I've seen many cases where the occupants of a vehicle that were involved in a crash were not able to give us much needed basic medical information. Any time we pull up on the scene of an accident our number one priority is to get the victims care as quickly possible, the "Yellow Dot" program is just one more tool that helps us help the patient.
 

wdk450

Well-known member
I'm a Kaiser Permenente HMO member here in Northern California. They will download your pertinent medical history, including medical imaging and lab test results, to a USB thumbdrive for $7. Updates are free for life, and the drive is protected by a numerical password you know. I keep the thumbdrive on my keychain, and it is labelled.
 

Silverado23

Iowa Chapter Leaders
, to a USB thumbdrive for $7. Updates are free for life, and the drive is protected by a numerical password you know. I keep the thumbdrive on my keychain, and it is labelled.
How do medical personnel get access to your medical history if you are not able to provide them your password during an emergency situation?
 

wdk450

Well-known member
How do medical personnel get access to your medical history if you are not able to provide them your password during an emergency situation?

MOST patients presenting in a medical facility are conscious. You can't cover every possibility. But I think I might change the password to the last 4 digits of my Drivers license number and mark that on the drive. Law enforcement has pretty ready access to your DL if it is not on you. Your vehicle/trailer will have plate numbers and registration paperwork with your name on it.
It was Kaiser's decision to set this up with a password. The password is not known by Kaiser, you enter it on a keypad. They are the nation's largest true HMO, and have a lot of emergency room experience. Their decision for password protection might have been swayed by our big-brother government's HIPPA medical privacy laws.
 

kowAlski631

Well-known member
Anyone at a Kaiser facility has access to your medical information. It is only when you go outside their environment that the information is not accessible except by the using of your thumbdrive or by accessing your information on line with your medical ID number. HIPAA laws do make insurance carriers & medical providers use passwords know only by the patient so that their confidential medical information is not breached. What I would do is to put the pw on the thumbdrive itself or use 1234 or 0000. You can't depend that anyone will realize that your pw would be the last 4 of your driver's license number. First though, check your files to see if they do have your date of birth or ssn on them. If they do, ask that Kaiser strip those out - they can do that, they just do a complete dump of info as that's easier on them. Martha
 

danemayer

Well-known member
Unfortunately, we had quite a few opportunities to use the Medical History Form this weekend. Ann fell off her bicycle and broke a few bones. Gave the form to the EMS team, the ER nurse, ER doctor, the attending doctor in the hospital, the orthopedic surgeon in the hospital, the nurses in the hospital, and the case manager. Every one of them had medical history questions and quickly got what they needed off the form.
 

danemayer

Well-known member
Btw, I'm really surprised that any hospital would plug a patient-supplied USB Key into their computers. USB Keys are known to have carried viruses that infect the system they're plugged into, along with the network the system is on. I would think that Kaiser Permanente is one incident away from finding another approach.
 

jimtoo

Moderator
Btw, I'm really surprised that any hospital would plug a patient-supplied USB Key into their computers. USB Keys are known to have carried viruses that infect the system they're plugged into, along with the network the system is on. I would think that Kaiser Permanente is one incident away from finding another approach.

After seeing some medical devices (USB storage) listed for sale on the internet and a couple of other places as medical emergency devices, I made a couple up. I have ask my Doctor's office (same place 30 years) and several other places, our local ambulance service, about 4 emergency rooms at hospitals, and none,,,NONE would plug a patient supplied device into their system. They had excuses from afraid of bugs to I don't know how or we are not allowed to use anything but what they have. So we carry a printed version medical history and also all drugs we use, prescription and supplements.

Jim M

Hope Ann is doing OK. ♥
 

ParkIt

Well-known member
After seeing some medical devices (USB storage) listed for sale on the internet and a couple of other places as medical emergency devices, I made a couple up. I have ask my Doctor's office (same place 30 years) and several other places, our local ambulance service, about 4 emergency rooms at hospitals, and none,,,NONE would plug a patient supplied device into their system. They had excuses from afraid of bugs to I don't know how or we are not allowed to use anything but what they have. So we carry a printed version medical history and also all drugs we use, prescription and supplements.

Jim M



Hope Ann is doing OK. ♥

I've kept a small font card I made up, laminated it and stuck it to the back of my drivers license. It has my primary doctors phone numbers, blood type and medications I'm allergic to in ER situations. Some look at it funny but think its a good idea even though one police officer said it was illegal (double side sticky tape so if they want to take it off, they can) and its come in handy quite a few times. Since your primary doctors/surgeons or hospital keep everything on record and can be found by your full name and date of birth printed on the license, it can be referenced quickly. They are also answering the phones 24/7.
Then there is the four page single spaced print out like Jim - I keep copies in my vehicle, the house and trailer and my son has one as well which is also printed on the card I made, it wouldn't take them long to get a hold of someone that can tell them what not to do just in case.
 

fdajnowicz

Member
The USB thumb drive is a great idea, BUT, when I went to use mine, the ER doctor could NOT plug it into their computer. STRICTLY AGAINST HOSPITAL POLICY. I am a heart attack bypass patient. While working closely with my cardiologist and primary physician they gave me pages of my medical records that they felt an ER Doc would need to treat me. I have an abnormal EKG, but it is normal for me. I have high T waves. If you were to run an EKG strip on me, the machine will tell you that I am having a Myocardial Infarction (heart attack). When an ER Doc sees this off to the cath lab you go. There is only one problem, I'm allergic to the IPD dye that is used during catherization. So I have a 23 page document that we carry when we camp to keep the issue of the USB thumbdrive from happening again. What I would recommend is talk to each of your doctors and ask them for copies of medical records/reports that they feel will help an ER doctor, also make sure you have the dates. List ALL your medications w/doses and intake schedule, ALL alergies, Special Medical events (surgeries/hospital stays) and diagnoses chronologically, ALL treating Physicians from when to when, Insurance Info and Emergency contacts. I keep this up to date and before a doctors appointment I print a new packet with an as of date on the cover and offer it to the physician/specialist, they will usually take the pages they want and put it in my file. I have had many a doctor thank me for the packet, because just about every question they have has an answer in there. It may be a lot of work, but saving time in the ER is the goal.

Frank
 

wdk450

Well-known member
I worked 28 years as a Hospital Biomedical Equipment Technician in a major regional medical center. I worked with mostly computerized networked equipment. FDA mandates that all hospital IT equipment have up to date antivirus protection. FDA has even given an exemption to medical device manufacturers for having to resubmit to the 510K approval process for equipment software changes due to anti-virus installation/upgrades.
Again, Kaiser, the largest HMO system in the U.S., issues these thumbdrives, with the data in Adobe format, for use wherever you are. They (and their IT experts) must believe the virus threat is minimal. Many USB secure flashdrives have embedded anti-virus protection (See: http://www.kingston.com/us/usb/encrypted_security/antivirus_protection ) .

I am now in Southern California, in another region of the Kaiser system, from that of my home region in Northern California. To use Kaiser here, I have to get a new patient ID set up, and they have to go through special protocols to retrieve my patient records. It is not automatic or simple. The Kaiser regional systems throughout the country have yet to be homogenized together.
 
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