Health Status of Wisconsin Residents

Health Record Keeping

The Importance of Health Records

Over the course of your lifetime, you will accumulate a large amount of health information. Not knowing where that information is when you or your loved ones need it can be frustrating.

The care system in the U.S. is changing in ways that require consumers to take more responsibility for their health. The preventive philosophy of health care demands that we move from passive recipients to active consumers of health care. Even though your doctor keeps records, you also should keep a handy list of the basics. This information has important implications for your well-being.

Knowing your family health history information can be very important.
Did your mother have breast cancer? Did your brother die of a heart attack? Did grandpa have glaucoma? Emerging research indicates that some diseases have a genetic pattern. Knowing your health history can help health care professionals diagnose and treat a problem more effectively. An accurate record of family health history can assist doctors in prevention and have life saving implications.
To create your own personal health record, download the forms below and follow the instructions for completion. A form should be completed for each member of your family. There are forms for adults as well as children. Your packet will include the following sections:

1. Personal profile/general information
2. Health care providers
3. Insurance information
4. Prescription medications
5. Allergies
6. Immunizations
7. Past medical history
8. Social history
9. Family history
10. Single medical incident report form
11. Chronic condition and treatment report form
12. Annual health record

To download the file for the Adult Health Record, click on this link:
http://www.uwex.edu/ces/flp/nnh/pdfs/ahrhand.pdf

1. Begin by completing your Personal Profile and your list of Health Care Providers. They will be useful quick references.
2. Insurance information should be complete and updated whenever yoursituation changes. List your medical insurance company and identification number if it is part of your plan. List the insurance plans, including Medicare, Medicaid, and information that applies to your situation. With the option of employers to change providers each year, this information is critical to keep up to date.
3. Accurate records of medication are important. Health professionals need to know what drugs you are presently taking because drug interactions can be a severe health threat. You will probably want to refer to the labels of the medication before filling out the Prescription Medications page.
4. Medical professionals will also need to know about any allergies you may have. This record allows you to keep track of allergies whether they are
   related to medications or to other sources. Complete this page by filling in any known allergies.
5. Immunization records are just as important for adults as children. Many recommendations have changed over the years and some are required over your lifespan, not just during childhood. You may need to refer to previous immunization records you have or contact your physician’s office to obtain the dates.
6. Your Past Medical History is a quick look at any previous hospitalizations or serious injuries.
7. Your Social and Family History are important because occurrences in the past can often have an influence in the present. It is important to be honest with your physician or health care provider about any of these risk factors.
8. Included in your packet are Annual Health Records. These forms need to be
   duplicated to provide sufficient space through the years. Separate record pages are provided for adult males, females and children to record annual medical information. You do not have to go back fifteen years to begin recording. Start your annual health record today. Fill in what you can and continually update it and add information. Use the Chronic Health Record page to track a particular illness over a period of time. The Annual Health Records section may be the most frequently used because it offers areas for recording routine and annual health check-up results and other tests.
9. The Single Medical Incident Report form allows you to track a single medical problem or a one time incident. A copy of this form is also included in the packet, but will need to be duplicated to provide space throughout the years.
10. The Chronic Condition and Treatment Report form allows you to continually track visits medications or other information related to this chronic medical condition. This form needs to be duplicated to provide sufficient space throughout the years.

There are other important things you may need to let other family members know. Additional resource pages may include such things as organ donor wishes, your choice for durable power of attorney for healthcare, and your living will declaration. You may want to add a plastic pocket or file folders for extra papers that you will keep as part of your health history.

Once your health record is complete, it should be stored in a handy place in your home. You might store it in a binder or expandable folder files. This is a valuable resource for your family and everyone should know where it is located.

To download the file for the Child Health Record, click on this link:
http://www.uwex.edu/ces/flp/nnh/pdfs/chrhand.pdf

The forms for your child’s health record are similar, with a few additions:

1. An immunization schedule for the first two years is included.
2. There is a form to describe the child’s birth and delivery history as well as
   specific illnesses.

As with your own health record, it is important to complete your child’s information and update it as necessary.

This lesson was developed as part of a multi-state project on consumer health sponsored by the Healthy People/Healthy Communities Initiative and the National Network for Health. Sereana Howard Dresbach Ph.D., Doris Herringshaw, Marcia Jess, and Bronwyn Smith provided the content for this lesson. The lesson was created by Jaime Chalk, Graduate Research Associate, The Ohio State University. Date: (2/2000).

Additional Resources

Wisconsin Immunization Program

Childhood vaccine schedules and requirements, adult vaccine and information schedules, specifics regarding influenza and pertussis, and additional resources. [more]