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Problem & Diagnosis Sheet

A quick index to your medical history.

Why this matters

The single most useful page in your record

The Problem & Diagnosis Sheet is a quick summary of your medical history — every significant diagnosis, surgery, and procedure with approximate dates. It is a sheet well worth the effort to prepare. Every doctor you see benefits from having it — and you benefit from having every doctor read from the same page.

Beyond its value as a summary, the sheet reminds your doctor what follow-up you need. For example, say you had thyroid surgery 10 years ago. After thyroid surgery there's a very high chance of an underactive thyroid developing — and the symptoms can be subtle until things get worse. A yearly thyroid lab screening catches it early. A problem sheet helps make sure the testing doesn't get overlooked.

How to fill it in

What goes on the sheet

Start by listing all the significant health issues and illnesses you've had. Then add operations and procedures. Write down approximate dates — they don't have to be perfect.

  • Don't list common, self-limited conditions like a single cold or a single episode of pain. Those clutter the sheet without helping.
  • Group related items when it makes sense. Multiple heart attacks, catheterizations, and bypass surgery can all sit under a single heading: "Coronary artery disease."
  • A simple chronological list is far better than no list at all. Don't let perfect be the enemy of good — start, then refine.
  • Update it over time. This is a working sheet, not a one-time exercise. Add new diagnoses and procedures as they happen.
Worked example

Significant diagnoses & conditions

YearDiagnosis / conditionNotes / treating doctor
1998HypertensionDr. Smith (PCP), well-controlled on lisinopril
2005Type 2 diabetesDr. Lee (Endo), A1C trending 6.5-7.0
2012Coronary artery diseaseDr. Chen (Cards) — includes MI, cath, stent
2014Hypothyroidism after thyroidectomyDr. Lee — annual TSH check
2019Chronic kidney disease, stage 3Dr. Hurwitz (NNH), eGFR 45-55 range
2023Mild osteoarthritis, both kneesManaged conservatively

Major operations & procedures

YearOperation / procedureWhere / surgeon
2012Cardiac catheterization with stent (RCA)CVPH, Dr. Chen
2014Total thyroidectomy (benign nodule)UVM Medical Center, Dr. Brown
2017Cholecystectomy (laparoscopic)CVPH, Dr. Park
2020Colonoscopy — 2 polyps removed (benign)Dr. Patel — repeat in 2025

My Problem & Diagnosis Sheet

Northern Nephrology & Hypertension Patient Personal Health Record

Significant diagnoses & conditions

Chronological. Skip colds and one-time events.
Year Diagnosis / condition Notes / treating doctor

Major operations & procedures

Surgeries, scopes, biopsies, ablations, cath labs
Year Operation / procedure Where / surgeon

Notes

Anything that doesn't fit elsewhere
Common mistakes to avoid

Where these sheets fall short

Listing every cold and ache A single bout of bronchitis ten years ago doesn't belong here. Keep the sheet to significant, lasting, or recurring conditions.
No dates at all Approximate is fine. "Thyroidectomy ~2014" is far more useful than "thyroidectomy."
Mixing symptoms with diagnoses "Chest pain 2018" isn't a diagnosis. If a workup found something, list that. If it didn't, leave it for the health diary instead.
Forgetting old surgeries That appendectomy at age 14, the wisdom teeth, the C-section — they all count. So do colonoscopies, biopsies, and ablations.

Print it. Carry it. Update it.

Hand a copy to every provider you see. Bring it to every appointment. Update it the day anything changes.

Take Charge of Your Health!

The Diagnosis or Problem Sheet:

A quick index to your medical history

The diagnosis/problem sheet will serve as a valuable and quick summary of your medical history. It is a sheet well worth the effort needed to prepare it. By keeping your own diagnosis/problem sheet, you will benefit by having this sheet available to every doctor you see.In addition to its value as a medical summary, it can remind your doctor what type of follow up you need. For example, let us say you had thyroid surgery ten years ago. Following thyroid surgery therre is a very high incidence of an underactive thyroid gland. The symptoms of an underactive thyroid gland can be very low grade until the condition worsens. By performing a yearly thyroid lab screening your doctor can pick up any developing condition early. A diagnosis/problem sheet helps ensure that the testing is not overlooked.

Get Started

A good way to begin is just to list all the significant health issues and illnesses you have had. Include operations and any procedures or treatments you have had. Write down approximate dates. Do not list common self limited conditions such as colds or a single episode of pain. A simple chronoligical list is better than no list at all. You could also group similar problems together such as multiple heart attackes, heart catheterizations or bypass surgery all listed under a heading of coronary artery disease. Below is an example.

Do the best you can setting up this sheet. It is a working sheet and should be udpated periodically. It does not have to be perfect. Remember that it is an ongoing process to reflect what you consider most important about your developing medical history.You now have a very quick index to your medical history. Bring a copy with you when you visit any doctor and have a copy available when you travel.In my medical practice, where I follow many patients throughout the years and some with very extensive medical records, I rely on an accurate and careful diagnosis-problem sheet. It is a very simple yet extremely important part of optimizing your health care delivery.

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