Medical History Report – More Tips

Having correct medical records is very important.

Through the years I have found that keeping a running Medical History of my son has been very helpful for me and for all who work with Corey such as the doctors. Many times I’ve gone to a new doctor to have the same questions asked and receive a report that was completed incorrectly. It is also difficult to remember the answers to all the questions as Corey gets older, especially when he did the milestones.

This was originally created after the first medicaid application and was used for the social history and medical history. We continue to use this every year by making a copy for medicaid and attaching it to the renewal forms.

Continue to read for Corey’s Medical Record outline without the personal information. You can use it as a guide to writing your own child’s record or your personal medical history. Throughout the outline I will add comments to clarify information or helpful tips such as the following:

Tip #1: Do this as soon as the medical records start coming in or delays are noticed. It will be easier to remember when the events are closer to when you record them.

Tip #2: Keep this posted with milestones, medical care, contacts, etc. on a regular basis.

Tip #3: Each year at a birthday or medicaid renewal, save this record under the year’s date. For example, “Corey’s Medical Records 2006.doc”. This will give you a saved look at that year for future use. Continue updating the original file with ongoing information.

Full Name Medical History
Address * Phone Number

Current Diagnosis:
List all the diagnosis given at this time.

Family Information:
Dad – name, age, employment, health status
Mom – name, age, employment, health status
Sibling – name, age, employment/school, health status

Pregnancy –
Delivery –

TIP #4 Tell a detailed history of the birth including child’s stats, unusual events, mother’s stats, location, doctor, date and time, etc.

Developmental delays were first detected:

Education – grade and school, type of class
Occupational Therapy – # hours/month with school OT & # hour/month with school OI, unable to schedule private
Speech Therapy – # sessions/week Kelly Ball and Katie Burch, Therapy Solutions, office # hours/week with school speech therapist
Physical Therapy – # hour session/week Katie Bannister, Tender Ones Therapy Services, office (8/10/06)
Hippotherapy – Began at 2.5 years old and ended in 2004 when he was 5 years old.
Swim Lessons – spring 2006 private went from choking neck grip to walking unassisted in 3 feet by August

TIP #5 At the bottom of every page use a “footer” with:
Name / Birthdate / Phone# / Page 1 / Date last updated

Medical Information:

Physicians – name, Pediatrician, name, Neurologist, name, Orthopedic Specialist, Dr. Ophthalmologist, Dr. , Pediatric Psychologist, Orthodics

Allergies – list medication/item and when developed allergy

Immunizations – Corey has been fully immunized up to Georgia requirements for his age.

Vision – date of last visit, doctor and results, diagnosis, therapy, surgery, patching, etc.

Hearing – date of last visit, doctor and results, diagnosis, therapy, surgery, etc.

Nutritional History – Example: Needs assistance in feeding on days he is sick or having seizures. He receives oral motor therapy during speech when needed for chewing and swallowing. Needs his meats ground or moist.

Adaptive Equipment – Equipment, date began and ended, age
Was it successful?

Medications – Current medication, dosage amount and time given

Past Medications – medication, dosage amount when last last given, how given and why it was discontinued.

Emergency Medication – medication, dosage amount, and when given

Tests – Test, date, location

Hospital History – Date and location submitted, reason

Evaluations –
Date Examiner Specialty Type of Test or assessment

TIP #6: Create a Table or Spreadsheet in a separate document with the evaluations. This can also be used as a cover sheet for your medical records book to access your master evaluations. Copy and Paste the evaluations in this section.

Diagnosis 1 History Beginning date and age: (Repeat this for each diagnosis)

Clinical Descriptions:
Actual Descriptions and Length: (This are for seizures)
Triggers: (This are for seizures)

Medication History: (Corey’s meds for seizures here separately)
1. Keppra 4/7/03-10/03 2. Zonegram 10/03-12/03 3. Lamictal 12/1/04-present 4. Trileptal 6/24/06 – 7/1/06
5. Clorazepate (Tranxene) 7/5/06 – present)
Emergency: Medication / date on-off

Seizure/Diagnosis History:
2002: running history

TIP #7: Diagnosis History Continued: If your information is cut by the page ending, put this caption at the top of the next page and continue.

TIP #8: BOLD dates that are important to view quickly such as seizures.

2006: SAMPLE DATA for seizures….
7/3 simple partial seizure 10 min. 5:47 pm
7/5 Clorazepate (Tranxene) 3.75 mg tab take ½ tab 2x daily
7/7 Pre seizure behavior at 9am before meds and not feeling well
7/10 Fever – pm partial seizure without stiffening
7/11 am partial seizure
7/24 8:55am 5 min. simple partial no screaming but some body tightening and aware at all times, said stomach and head hurt
8/10 7:45am was very cold at breakfast and said he did not want to have a seizure. Left his breakfast to sit in the big chair with covers and had about 30 sec. partial seizure. No screaming, some tightening. rest of the day good
8/28 “momma” 7 minutes at school 1:50
9/23 3 tightening episodes within 5 minutes, light whimpering only – very mild

Current Functioning:
Also see the therapist care plans and psychodevelopmental evaluations for details and test scores.

TIP #9: In each of these sections, write the current level of functioning, how is it being addressed and by whom, concerns and success being made.

Self Help

Fine Motor Skills

Gross Motor Skills

Behavior 1:
Behavior 2:
Behavior 3:

Social Skills



1. Great personality. Caring, sharing, hugs and kisses, laughter and the sweetest smile
2. Works hard and many hours to progress and is proud of himself when he makes progress
3. Very good medical treatment and early care has shown great improvement
4. Full parent and family love, support and involvement
5. Good school support and loving teachers and friends
6. Works hard at therapies and home to be the most he can be
7. Quality direct and supervised skilled care received on intense, consistent basis is showing response towards independent functioning
8. Visual understanding and enjoys music, animals, friends, and running.

Make this a numerical list with specific individual needs addressed. Corey’s list has 39 needs. Use the IEP, therapy goals, etc. for data.

Level of Care:
Make this a numerical list with specific individual level of care addressed. Corey’s list has 5 levels. Your doctor, therapists and your own personal experience can be used for the data.

List of Firsts and History

For the first 2 years I went by months with the actual date and milestone. In year 2 I switched to just the years. This also included doctor visits and brief results, seizures, medicine changes, school and class information, etc.

1 wk. Date milestone

3 mo. Date milestone

2 years
3 years

TIP #10: Make a page break

People who help Corey
TIP #11: I keep a copy of this page in my address book. You may want to keep it in other locations also like your purse for easy access.

School Phone Address
, Principal Email
, Vice Principal Email
, Asst. Princ. Email

School Nurse: Phone Email
County Nurse: Phone Email / FAX
, Speech Email
, OT Email
, OI Email
, Teacher Email
, Parapro Email
, School psychologist Email

Private Therapists:
Name, Specialty – Company, Office Phone, Cell, Fax, Address, Email, Website
*Repeat for each therapist

Current Doctors:
Name, Specialty – Company, Office Phone, Cell, Fax, Address, Email, Website
*Repeat for each Doctor

Prescriptions filled at Store Name: Phone Fax Address

School Permission for Pickup:
Name, Phone, Address, Relationship

*Add Medicaid Application and Renewal:

Brief explanation of medical necessity, success and thank you for help, and ask to continue services or be accepted for services.

I also include a recent picture of Corey. If you are using Word or another word processor you can Insert a photo and have it printed in this document.

TIP #12: When writing this information, think of another person having to use it to take care of your child in case something happened to you. What would they need to know to give your child the best care possible?

Corey’s document is up to 17 pages on his 8th birthday. Yours may have more or less.