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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