Welcome to Patient Advocacy Initiatives' Digital Universal PreHistory (PreHx).
Ready to help assemble information for your medical provider
and be your own patient advocate?
Let's get started
Hey! A payment field in this typeform can’t load in your browser. To pay, please view this typeform in one of these browsers—or submit without paying.
Welcome to Patient Advocacy Initiatives’ universal PreHistory (PreHx). This is your chance to be better heard and understood when you visit a medical provider. Please complete this form and bring it with you to your next medical encounter. At the registration desk, to the triage nurse and to your medical provider, submit your PreHistory as a written request to amend your medical record per the HIPAA Privacy Rule [45 C.F.R. § 164.526]. Learn more at www.PatientAdvocacyInitiatives.org

The PreHistory is designed to help you prepare for a medical encounter. At best, your words could co-author what is written about you in your health record. Once you submit this form to your healthcare provider, then this information becomes Protected Health Information  and is subject to federal laws for privacy and security. Completing this form is free. If you feel value from our effort to provide you with this information and our online support for this patient right, we encourage you to donate to Patient Advocacy Initiatives, a 501(c)(3) Pennsylvania non-profit organization. We will monitor responses to help improve patient communication. We do not provide medical care or advice. We hope to improve medical documentation so our healthcare system can better care for you. We believe valuable clues are in your story. 
Thank you for using our PreHistory form.
Legal: We are not functioning as your doctor. Our goal is to help you prepare to see the doctor and to potentially improve information in your medical record. *

These medical interview questions have been defined and structured by Centers for Medicare and Medicaid Services (CMS) 1995 & 1997 Evaluation and Management Documentation Guidelines.

It is our goal to help you prepare for a visit to a medical provider. In completing a PreHistory, you are not establishing yourself as a patient with our organization. Please know we are not able to respond to what you write in your PreHistory. The contents of all PreHistories will be used to help better understand the concerns and needs of patients. What you write in your PreHistory will not be associated with your identity.

We encourage you to visit www.PatientAdvocacyInitiatives.org and download and print our paper PreHistory. This form will allow you to prepare for your next visit with a medical provider.

Is this your first time completing a PreHistory? *

Please answer a list of questions that our government has defined and structured for a doctor to ask you during a medical interview. Your doctor may not have the time to ask all of these questions and document your responses, but you can help. Your medical story, as portrayed in your own words with this PreHistory, will help paint an accurate picture of your medical concerns. We hope this will lead to an accurate diagnosis and treatment plan.  
Let's get started!

Are you completing this PreHistory for yourself or on behalf of another person? *

How are you associated with the person you are helping to complete this PreHistory? *

How would you describe your role with this person outside of family member, friend, caregiver? *

Please enter the first name of the person for whom this PreHistory is being generated *

If you are completing this PreHIstory for someone else, please answer questions as if you are this person.
Last name please *

Let's answer a few demographic questions to make your PreHistory look great. What is your gender? *

If you are completing this form for someone else, please asnwer remaining questions as if you are the person preparing for a medical encounter.

What is your year of birth? *

Please enter four numbers. If you were born in 1972, then enter 1972
What is your month of birth? *

Please enter one or two numerical digits to describe the month of your birth. 
01 January, 02 February, 03 March, 04 April, 05 May, 06 June, 07 July, 08 August, 09 September, 10 October, 11 November, 12 December
What is your day of birth? *

Please enter one or two numerical digits to represent which day of the month you were born. If you were born the tenth day of the month, then enter 10
What is/are your Chief Complaint(s)? *

Chief complaint is the reason why you seek medical attention. It can be more than one problem, such as "Cough, foot pain." For a person who sees a medical provider for Hypertension, then "Hypertension Management" is a great chief complaint.

Keep in mind, a doctor can only record one History per medical encounter. You should, therefore, only complete ONE PreHistory for each medical encounter.
Let's now complete the History of Present Illness (HPI). This section is the who, what, when and why of the medical interview. 
Where on your body is the problem located?


LOCATION is one of 8 HPI components. Location describes where the problem is located on or in your body. While a person with back pain could enter "back," we encourage you to be more specific. "Left side of my lower back" is more specific.

Sometimes, the location does not make sense. A person who feels anxious, for example, may write: "Not applicable" for location.
What does your problem look or feel like? *

This is the QUALITY component of the History of Present Illness (HPI). A person with a rash may describe it as feeling "itchy" and looking "bumpy and red." Do your best to describe what your problem makes you look or feel like.
How bad is your problem from 1 (very mild) to 10 (worst it can be)? *

SEVERITY is an HPI measure that allows you to rate how bad your problem is.

How long have you had this problem? *

DURATION is a component of the HPI that asks how long you have experienced this problem. For the person who was injured two weeks ago, then "two weeks" is the duration. A person who has had diabetes for a long time could write "since I was age 5" or "since 1967."
When does this problem occur? *

TIMING is one of the 8 HPI components. Does your problem occur all of the time (constant) or only certain times during the day or night?
Think of the time on a clock when you answer this question.
For example, if someone experiences back pain in the early hours of the morning, the person could document: "early morning hours."
Can you describe any circumstances that occurred or continue to occur in relation to your problem? *

CONTEXT is an HPI component that can describe what happened when you first got the problem. For example, "I was jogging in the park and I tripped on a branch and fell." 
Context may also be used to see what precipitates your problem. Are there any circumstances when the problem occurs?
What makes your problem better or worse? *

MODIFYING FACTORS is one of the 8 HPI components. What makes your problem better or worse? The person with back pain could write: Better with rest and ibuprofen, worse with activity.

Do you have any additional comments about your problem(s)? *

ASSOCIATED SIGNS AND SYMPTOMS is the one of the 8 HPI components. This category allows you to add additional information that was not captured with the previous HPI questions.
Do you have any chronic medical conditions or diseases? Please give an update. *

For example, a person who has diabetes, hypertension and high cholesterol can use this section to provide an update of his/her experience with disease. 
A patient with diabetes may offer home glucose readings, medication adherence (taking medications?) and potential side effects, activity and dietary habits, and if another medical provider was seen for the co-management of disease care.
Diseases you describe here should match what you wrote in your chief complaint.
Let's begin the next section of your PreHistory, called the Review of Systems (ROS). ROS is a head to toe/mind-body checklist. 
How are you feeling overall? *

"How are you feeling overall?" is the CONSTITUTIONAL part of the ROS. How is your energy level? Have you had any changes in your weight (loss or gain)? For a person who feels well, this area might read, "I am feeling well. I have good energy levels and my weight has not changed."
Review of Systems: EYES
Do you have any problems with your eyes, such as blurry vision or loss of vision? *

If you do not have any problems with your EYES, you can write "No problems"
Review of Systems: EARS, NOSE, MOUTH, THROAT Do you have any problems, such as an earache, mouth pain or sore throat? *

If you do not have any problems with this area of your body, you can write "no problems."
Review of Systems: CARDIOVASCULAR
Do you have any chest pain, chest tightness? Do you experience any swelling of your legs? *

Of interest, swelling in your legs is a part of the CARDIOVASCULAR category of the Review of Systems
Review of Systems: RESPIRATORY
Do you have any difficulty breathing or shortness of breath? Do you have a cough? *

Do you have any problems, such as trouble eating or moving your bowels? Do you experience abdominal pain or heartburn? *

Review of Systems: GENITOURINARY
Do you have any trouble urinating or genital issues? *

Review of Systems: MUSCULOSKELETAL
Do you have problems with your musculoskeletal system, such as joint or muscle pains, or stiffness? *

Review of Systems: INTEGUMENTARY
This section addressed your skin. Do you have any skin color changes, moles or rashes? *

Review of Systems: NEUROLOGIC
Do you have any problems such as numbness, pain or trouble moving? *

Review of Systems: ENDOCRINE
Do you experience fatigue or increase in thirst? *

Review of Systems: PSYCHIATRIC
Do you experience any mood changes, feelings of depression or anxiety? *

Do you experience bruising or swelling in your legs and arms? Do you have any swollen glands? *

Do you experience seasonal allergies? Do you have any allergies or reactions that are not part of your allergy list? (we will get to allergy list soon) *

Let's now complete the Past Family Social History (PFSH) part of your PreHistory. Let's start with your MEDICATION list. 
Please list you medications. These can include prescription medications, over the counter medications and supplements. 
If you take no medications or supplements, then write "none." *

The best way to list your medications is to write the name of the medication followed by how and why you take it. Lisinopril, for example, is an Angiotensin Converting Enzyme inhibitor that can be taken to control blood pressure. A person taking this medication for hypertension may write:

Lisinopril 10mg one pill by mouth once a day for hypertension.

If you take multiple medications, place a comma after each medication and description.
Do you have any allergies to medications? *

If you have an allergy to Penicillin that caused a rash, then write: Penicillin (causes rash)
If you have no allergies to medications, you can write "none" or "no known drug allergies."
PFSH: ALLERGIES beyond medications
Do you have a non-medication allergy, such as to bee stings, cats or peanuts? *

Please describe your allergy and the effects of exposure. A person with an allergy to bee stings could write: Bee stings (swelling, pain, shortness of breath)
Do you have a history of disease that has not been mentioned so far in your PreHistory? *

If you are seen for the chronic care of Diabetes mellitus, you could write: "Diabetes mellitus since 1995" here. Imagine a female who experiences Gestational Diabetes while she was pregnant in 2004, but has had no evidence of elevated blood glucose since. She could write: Gestational diabetes (2004)
This section is likely to generate a list of problems that you have had in the past. This is valuable information.
This is where you list your previous surgeries. *

This section could look like this:
Appendectomy (1968), Breast biopsy (2007)
Try your best to describe your condition. "Appendix removed (1968)" is ok too.
Please report about your family. Do you have any children? Are your family members healthy? Do any diseases occur in your family? Has any member of your family become ill since your last medical encounter with this medical provider? *

For example, "Daughter 'Megan' born 1999 - healthy, Father died age 67 - lung cancer/smoker, Mother/Brother - healthy, Sister with arthritis."
This is where you can describe elements of your lifestyle, such as marital status, occupation, tobacco smoking, alcohol use, recreational drug use. *

You can also note whether you experienced any changes. For example, if you got married or accepted a new job, this is the place to document this information.
Please enter the date you would like displayed on your PreHistory *

You may enter today's date or you may enter the date you expect to have your next medical encounter. 
Please list Month, Day and Year as you see fit. 05/01/2018 is fine, so is May 1, 2018   :)
You just completed a PreHistory in preparation for your next medical encounter. 
To obtain your PreHistory, expect to receive a digital copy to the email you provided. Once you receive it, you may print it to paper and/or send it electronically to your medical provider in preparation for your next medical encounter.

This PreHistory form is provided to you FREE OF CHARGE by Patient Advocacy Initiatives.

Would you like to make a $5 donation to this non-profit organization? *

Patient Advocacy Initiatives is a 501(c)(3) non-profit organization registered in the State of Pennsylvania

Donate $5 to non-profit Patient Advocacy Initiatives. {{var_price}}

Thank you for this donation. Your funding will help us teach individuals how to be their own patient advocate!
Sorry, your browser doesn’t support payments
Thank you for visiting our universal PreHistory!
Please visit www.PatientAdvocacyInitiatives.org for more information on how you can be your own patient advocate
Powered by Typeform
Thank you for using our universal PreHistory to help you prepare for your next medical encounter! 
Please expect your PreHistory to arrive to your email address. 

By reflecting over these questions in advance of seeing a medical provider, you are engaging in a new role as a member of the healthcare team.
After your next medical encounter, request to access a copy of your medical record to assure that your story was properly documented. 
Learn more about being your own patient advocate at www.PatientAdvocacyInitiatives.org
Powered by Typeform
Powered by Typeform