Article Index

Documentation

While the description of your concern should be verbal, there are certain routine facts that every healthcare provider should have. A written list of these may help.

Demographics – It is helpful to indicate at the top of any list your age, sex, occupation, marital status and ethnic background. Some diseases are unique to certain occupational, ethnic, or geographic backgrounds. Include any insurance information.

Medications – A list of your current medications is essential. Drugs that your doctor might consider for your present disorder may interact with current drugs.

Perhaps your concern is due to an adverse reaction to a treatment. The list should include the dose and the frequency of the medication, and the length of time you have been taking it.

Other Treatments – Have you received any other treatments? Your provider will want to know what has been tried in order to plan management. Moreover, not all "alternative" treatments are harmless.

Sensitivities – This list should include drugs to which you have had an adverse reaction such as a rash, jaundice, or gastrointestinal upset. Allergies to insect stings, hay fever, allergic asthma, or contact dermatitis are also important.

Many reported sensitivities are unsubstantiated. As this could rule out use of certain drugs or diets, you should indicate any evidence you have that they are truly present.

Previous illnesses – This should include the important illnesses you have had in the past, especially those that have led to disability, hospitalization, or surgery.

In the case of surgery, it is important to be sure what was removed and what was left in. It may also be helpful to indicate the doctors who treated you for these illnesses because your present doctor may wish to contact them. Inheritable diseases such as heart disease or cancer in first degree relatives should be listed as well.

Other Factors – Tobacco, alcohol, and recreational drug use are important to reveal.

These lists should be as brief as possible and clearly written so the provider can include them for future reference in your record. This avoids the need for the doctor to write down the lists you give him verbally, avoids mistakes, and saves time for you to describe your main concern.

Working with Your Doctor

patient doctor

Successful relationships with healthcare providers are an important part of managing life with a long-term digestive disorder.

Doctor–Patient Communication

How to Help Your Doctor Help You

How to Talk to Your Doctor