My Medical History: What My Surgeon Needs to Know

None

It can be frustrating being a patient. You see many healthcare providers and they ask many of the same questions. Not another form! Isn't it all in my chart?

Your surgeon needs to know your health history so that they can take good care of you. Unfortunately, there are many different record keeping systems, including paper charts as well as myriads of electronic medical records. And just like people who speak a different language, they don't all communicate with each other. How can you help?

Keep your own personal medical history. These include:

Medications and supplements you currently take:

  • including any herbal medications you use

Allergies:

  • including specific allergic reaction to each medication or product

Previous surgeries: 

  • including date, surgeon and hospital/ clinic
  • obtain pathology reports if tissue was removed              

Previous anesthesia: 

  • and if you had any difficulties with the anesthesia or intubation (getting the breathing tube in)

Previous bleeding problems:

  • including history of blood transfusions

Previous hospitalizations and ER visits:

  • including dates, hospital, diagnosis and treatment

Previous imaging and testing:

  • including all x-rays, lab tests, diagnostic procedures

Family history: 

  • including major medical problems and allergies
  • Consider making a family tree if any family members have been diagnosed with cancer. It is helpful to know the age at which cancer was diagnosed and the exact type of cancer. This will help determine if you may carry a genetic defect that makes you prone to cancer.


By keeping your own records and verifying your medical records with your physicians, your doctors will be equipped with the information they need to care for you. In these times when people are mobile, insurance plans changes, doctors move or retire and hospitals and clinics change hands, patients are wise to have their information in their possession.

If your doctor or clinic allows you to electronically sign into your medical records, strongly consider creating your electronic account. You will have access to your doctor and your health information wherever there is Internet access.