What Should I Document?
AS YOU BUILD YOUR MEDICAL HISTORY, BE SURE TO ANSWER THESE QUESTIONS IN YOUR DOCUMENT:
• When did you begin having headaches that impacted your quality of life?
• Explain the frequency and severity of your headaches.
• What are the symptoms associated with your headaches( e. g., paralysis, nausea, vomiting, sensitivity to light and sound)?
• What is the typical duration of your headaches?
• Do you experience visual aura( e. g., blind spots or flashing lights) or paralysis before the pain starts?
• How often are you using pain-relieving medication and how much do you take?
• If female, do you find that you have headaches around the time of your menstrual period?
• What treatments have you tried, and what was the outcome of using those treatments? Did you experience side effects?
• Do you experience sleep disorders, such as insomnia, excessive daytime sleepiness or sleep apnea?
• Do you experience personal stress( work, marital, etc.)?
• Do you have a family medical history of pain syndromes( e. g., fibromyalgia, cluster headache, migraine)?
• What hobbies, interests or exercise programs do you enjoy?( These could be used as part of your treatment plan.)
Note: This is a general list and you should customize it to fit your condition.
The headache diary is a vital component of your medical history. If you’ ve kept an accurate, consistent record of every time a headache started and ended, what you were doing when it started, what foods you consumed prior to the headache and any associated symptoms( e. g., nausea, vomiting, sensitivity to light and sound), this can help you and your physician identify patterns, investigate triggers and determine if treatments are working. Be as detailed as you can and don’ t hesitate to mention seemingly minor symptoms or reactions. Dr. Messina says one of the mistakes many patients make is only noting major migraine events, omitting mention of low-grade daily headaches and less-intense migraines. It is important to make note of all headaches as the number and type of headaches could impact your diagnosis and treatment.
Plan to also include a list of questions that you’ d like to ask once you receive your diagnosis and treatment plan, including questions about medication dosage, prevention strategies and any special instructions.
FIND HELP CRAFTING YOUR HISTORY
Pertinent information compiled in an organized manner( e. g., a ring binder or folder) allows your physician to access data when needed, Dr. Cooper says. Ideally, you should bring this information to every clinician encounter to allow your medical team to have access to your medical records when needed.
If you aren’ t sure how to get started, Dr. Messina recommends using Arbor Medicus™, a tool he developed to help patients think through important questions before their appointments. The tool requires a login, allowing you to keep your information confidential. After logging in, a“ video nurse” will walk you through several questions, building a history that you can then e-mail to your doctor or print a copy to bring to your visit. To access the tool, go to www. ArborMedicus. com.
While documentation is significant, keep in mind that it will also be important to communicate effectively during your appointment. Before your appointment, practice discussing how headaches have affected your quality of life and how the pain is impacting your daily activities.
“ The biggest challenge for many patients is the feeling that their symptoms are not being taken seriously,” Dr. Messina says.“ A decent doctor presented with the right information is going to act on it. If you feel the physician is not listening, you need to find another doctor.” HW
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