You’re in a doctor’s office with a clipboard and a pile of medical forms on your lap. For the umpteenth time, you must now jot down your medical history — conditions, ongoing symptoms, past procedures, current medications, and even the health of family members.
But how much information should you include? Which details are most important? And why are you slogging through paper forms when a digital version likely exists? Put down your pen for a moment and take a breath. We have some answers.
Do you actually need to fill out the forms again?
In many cases, you do need to fill out medical history forms. That can be true even if you already have a digital record on file, known as an electronic medical record (EMR) or electronic health record (EHR).
The reason for collecting new information could be due to a variety of reasons:
- The health care provider might want an update, since information like medications or new health problems can change over time, or you might have missing or inaccurate information in your record.
- Different specialists need to know about different aspects of your health.
- Your EMR at one provider’s office might not be accessible to others because practices don’t always have compatible computer software.
- Some practices don’t want to rely on records created by other practices. They may not trust that they’re accurate.
What if you don’t want to fill out the forms?
“You don’t have to,” says Dr. Robert Shmerling, a rheumatologist and senior faculty editor at Harvard Health Publishing. “But the response from the practice might be, ‘How can we provide the best care if you don't provide the information?’ And if you persist, you run the risk of marking yourself — unfairly, perhaps — as uncooperative.”
What are the most important details in your medical history?
The most important details of your medical history include
- chronic or new symptoms and conditions
- past surgeries
- family medical history
- insurance information
- current prescription and over-the counter medicines, supplements, vitamins, and any herbal remedies or complementary medicines you use
- medication allergies
- vaccination history
- any screening tests you’ve had, so they won’t be prescribed unnecessarily
- any metal implants you have, which could affect screenings.
If you don’t know all of the details, try to get them from a previous doctor or hospital you’ve visited.
“In some cases, not having the information could be a problem. For example, I need to know if my patients have had certain vaccines or if they have medication allergies,” says Dr. Suzanne Salamon, associate chief of gerontology at Harvard-affiliated Beth Israel Deaconess Medical Center.
Which information might be less important?
Sometimes, leaving out certain details might not matter, depending on the purpose of your health visit. For example, your eye doctor doesn’t need to know that you broke your wrist when you were 18, had the flu last year, or had three C-sections. But they should know which medicines and supplements you take, and whether you have certain health conditions such as diabetes or high blood pressure.
Not sure what to leave in or out of your history? Dr. Salamon suggests that you at least focus on the big stuff: chronic symptoms and conditions that need ongoing treatment, medications and supplements you’re taking, and your family medical history.
“If you can, bring a copy of your medical history to all new doctor appointments. It could be written or printed from your patient portal or kept handy on a digital health app. That way, you’ll have it handy if you need to fill out medical forms or if the physician asks you questions about your medical history during an appointment,” Dr. Salamon advises.
How secure is the information you’re providing?
We trust health care professionals with our lives and our most private information, including our social security numbers (SSNs). SSNs are used to double-check your identity to avoid medical errors, and to make sure your insurance information is accurate and practices get paid.
Is it really safe to hand over the information? It’s supposed to be. A federal law called the Health Insurance Portability and Accountability Act (HIPAA) protects your health information with very strict rules about who can access it and how it can be shared.
“Medical practices take this very seriously,” Dr. Shmerling says. “They have lots of safeguards around personal health information, and routinely warn medical staff about not looking at or sharing information inappropriately — with the threat of being fired immediately if they do. Electronic health records usually track those who look at our information, so it's often not hard to enforce this.”
But no hospital or other entity can guarantee that your information is protected. That’s true of all information, especially with the constant threat of cyberattacks.
“So if you feel strongly about it, you can try saying that you’d rather not provide certain information and ask whether the practice can explain why it’s necessary,” Dr. Shmerling says. “It takes a certain amount of trust in the system that personal health information will be kept private, even though that may feel like taking a leap of faith.”
About the Author
Heidi Godman, Executive Editor, Harvard Health Letter
Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman
About the Reviewer
Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing
Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD