My Medical Information Worksheet
WHAT DO I NEED TO KNOW ABOUT MYSELF AND MY HEALTH?
If I don’t know, I will ask my doctor and find out! KNOWLEDGE IS POWER! I will have this information at all times and make sure to update it every year.
Diagnosis: INFLAMMATORY BOWEL DISEASE – which of the following do you have?
o Crohn’s disease
o Ulcerative colitis
o Indeterminate colitis
How was I diagnosed?
o Endoscopy
o Upper (EGD)?
o Lower (colonoscopy)
o Both
o Date and location of procedure (what hospital?):
o Were biopsies taken?
o What are the results? Do I have a copy of these results?
Who is my doctor?
List all doctors – your primary care physician, GI physician, and/or medical team.
o Name: o Address: o Phone/Fax: o Email:
What other medical conditions do I have?
o Name of condition(s):
o Date of diagnosis:
Have I had all my vaccines?
o Yes
o No – which ones have I not had and why (reaction, preference)?
What medications and treatments am I taking?
COMMON IBD medications:
• Mesalamine, steroids (prednisone, budesonide)
• 6-MP, Imuran, methotrexate
• Remicade, Humira/Cimzia/Simponi
• Vedolizumab/Tysabri
• Stelara, Xeljanz
• Enteral nutrition, other dietary therapy
o Name of medication or treatment: o Dose and how often taken: o If an infusion, when was the last infusion and at what dose? o Do I think the medication works for controlling my disease?
Pharmacy
o Name: o Address: o Phone:
o Fax:
What allergies to medications do I have?
o Medication name:
o Describe the reaction:
What medications have I tried for my IBD that have NOT worked for me?
o Name and dose (if available): o When tried (dates/situation): o Why was the medicine stopped?
What disease issues have I had?
o Intestinal strictures
o Fistulas
o Abscesses
o Liver disease
o Pancreatitis
o Joint problems
o Rashes/skin/mouth ulcer issues
o Eye issues
o Bone problems o Kidney stones o Other
How many times have I been hospitalized?
o Dates of hospitalization(s): o Reasons for hospitalization(s): o Location of hospitalization(s):
Have I had any surgeries?
o Dates of surgeries: o Reasons for surgeries: What part of the intestine was removed? o At what hospital did surgery occur? Who did the surgery?
Have I had blood transfusions?
o Date of blood transfusion:
o What blood products were received (blood, platelets, plasma)?
Important monitoring tests
Provide dates and results; need to know MOST RECENT testing for each.
o Endoscopies: o Radiology (MRI, CT scan, ultrasound, X-ray): o Bone density tests (DEXA): o Vitamin D level: o Ophthalmology evaluations, dermatology (skin cancer checks): o TB (tuberculosis) skin tests (or Quantiferon blood test): o TPMT and metabolite level if using azathioprine or 6-MP: o Level of biologic medication (such as Remicade or Humira), if checked:
