Making medical history forms more inclusive
We all know it: every time we visit a doctor’s office for the first time, we are presented with it. The medical history form. To write down all the data required by the practice. Even in 2023, I’ve only ever seen one practice in my life where I was handed a tablet and asked to fill everything in digitally. But let’s start again…
Why do I need a medical history form?
A medical history form is an important document used by doctors and therapists to collect information from patients that is relevant for medical diagnosis and treatment. However, it is also important to note that patients usually have to fill it out on their own. This usually requires a good knowledge of German. It should therefore be possible for the form to be completed together or for it to be offered in other languages. The total amount of information required always depends on the respective specialist area.
What belongs in a medical history form?
Here are a few points that may be included in a medical history form:
- Contact details: This is standard information, for example to know which health insurance company the patient is with and the contact details. For many practitioners, it is important to state the type of paid work performed in order to know for the diagnosis whether the cause could also be due to special features of the work (shift work, stressful situations, etc.). Particularly if practices or clinics attach importance to sensitized interaction with patients, fields for the following points should also be included:
- Desired form of address (first name + surname or surname only, pronouns)
- 1st and 2nd language
It can also be important to know the biological sex, as the course of the disease and the effect of medication can be different depending on the hormonal background. In some cases, examination devices are set to average values of binary genders (male and female), which can lead to extreme values being measured in the case of an unknown transition. - Symptoms and complaints: It is important to note current symptoms and complaints, ideally with duration, severity and any triggering factors.
- Allergies and intolerances: An anamnesis form should contain information about known allergies and intolerances to medication, food or other substances.
- Family medical history: Information on family medical history is important for practitioners, as genetic predispositions must be taken into account for certain diseases.
- Lifestyle and habits: The medical history form may also include questions about lifestyle factors such as diet, alcohol and tobacco consumption, exercise and stress, as these factors can affect a* patient’s health.
- Social factors: Information about social status, occupation, place of residence and social support systems can also be important in understanding a patient’s health and well-being.
- Travel and exposure history: If the patient has traveled to areas with certain infection risks or is exposed to occupational risk factors (e.g. chemicals), this is relevant for diagnosis and treatment.
- Patient’s current problems and questions: The medical history form allows the patient to note any current problems and questions they would like to share with the doctor.
A detailed medical history is crucial as it helps the doctor to get a comprehensive picture of the patient’s health and needs. This information is necessary to make an accurate diagnosis, plan appropriate treatment and ensure that the patient receives the best possible medical care. However, it is always possible that the medical history forms are kept simpler and shorter so that patients are only asked for the absolutely most important information when they are first admitted. The other information is then obtained from the conversation between doctor and patient.
The medical history form in psychotherapy
The anamnesis form in psychotherapy has a special feature, as it is used when the therapist and patient decide to start therapy and probationary sessions have taken place and a place in therapy is available. However, this medical history form also covers points that are relevant to the therapy. Which complaints bother the patient the most? How long has this been going on?
It is important that patients express their individual wishes and goals themselves, as psychotherapists cannot simply prescribe them. This is part of the patient’s interest in participating in therapy and also in working on their own behavior and ways of thinking. Otherwise, this can lead to the therapy being terminated without success.
The medical history form also supports the therapist after the discussions with the patient in order to submit the necessary report and diagnosis to the health insurance company before therapy begins.
How do I design a gender-neutral medical history form?
First and foremost, it is important to adapt the gendered form of the word “patient” wherever it appears. For example, the form could simply be called “Medical history form” and the heading “Personal details”
If it seems too impersonal, inclusive gendered forms of address such as “patient” can also be used. The gender star is recommended here, as this is used most frequently in the queer community and is also recommended by several official bodies. The German Association for the Blind and Visually Impaired also recommends using the gender star if gender-neutral formulations are not possible, as this is the most easily recognizable and therefore makes it clear to readers what is implied by the sign. Text readers, as used by some people, make a pause, similar to the glottal stop in verbal language.
Including anamnesis forms for free download!
Queermed currently offers free medical history forms for the specialties “General Medicine”, “Gynecology” and Psychotherapy – Behavioral Therapy for download and use. Ideally, we ask you to refer to the medical history forms.
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