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Resources: Medical Summary

Document Toolkit

These documents are meant to be helpful and adapted for your use. Please feel free to print out and use these to create your own.

Medical Summary Example:

Use this as a resource for summarizing medical history and current medical status.

Print it out and keep a few copies with you so you can provide it to others as needed. Remember to update it regularly. [Printable PDF]

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MEDICAL SUMMARY LETTER – [CURRENT DATE]

 

PATIENT NAME:

DATE OF BIRTH:

MEDICAL HISTORY:

One paragraph to summarize overall diagnosis 

SURGICAL HISTORY:

[Month, Year]: 1st Surgical procedure, hospital where it was done

[Add all surgeries related to diagnosis; if none, write in None]

RADIATION HISTORY:

[Month, Year]: Number of days; radiation type; where on body; hospital where it was done

[Add all radiation treatment received during lifetime; if none, write in None]

CURRENT MEDICINES:

Dose, medicine, schedule

[List all, including vitamins, daily medications, medications taken as needed, and infusions received in the hospital]

For example:

  • 2 mg of Dexamethasone daily
  • 20 mg of famotidine 2x daily
  • 1 mg kytril as needed
  • Daily multivitamin; 50 mg B6, D3
  • Last Nivo/Ipi infusion: January 5, 2025

SOCIAL HISTORY:

This is where you can tell a little about yourself or your person. For example, share what you do for work or if you’re in school and if you’re still able to attend; your hobbies; what you like to do or used to do and how the disease has affected that; what’s important to you. Remember to keep it to a short paragraph. You want people to be able to skim the information quickly.

CURRENT STATUS:

Share your (or your person’s) symptoms. Where are you feeling diminished sensations? Are you having any difficulty with movement or walking? Any issues with hearing or vision? Bathroom issues? Just an overall picture of what the person is feeling on a daily basis.

HISTORY OF PRESENT ILLNESS

This may be the longest section. This will be a timeline of when the symptoms started and when treatments were received. If you had a cancer diagnosis many years ago and were fine for years, add that in as well. Be sure to include doctors seen and hospitals visited

For example:

July 2024

  • Presented with severe headache and dizziness at urgent care. Diagnosed with a virus.
  • Two weeks later, not improved. Sent for a brain MRI at County General Hospital. Results showed one large mass and signs of leptomeningeal enhancement.
  • Referred to Michael Smith, Neurooncologist


August 2024

  • Began treatment with X medicine on August 23, 2024. Overall, tolerated treatment well except for some fatigue and leg soreness.
  • Received X treatment at 5 mg/kg every 3 weeks until October 2, 2024.


October 2024

  • Went for second opinion at City General Hospital and was seen by Amy Grant (neurosurgeon), Dr. Lisa Jones (neuro-oncologist) and Dr. John Stone (radiation-oncologist). They recommended XYZ.
  • Started XZY treatment plan on October 30, 2024


November 2024 to April 2025

  • Saw improvement with symptoms
  • Started experiencing numbness in the right leg in April 2025.
  • 4/8 – Brain & Spine MRI at City General Hospital.
  • 4/9 – Had an episode at work of confusion and stumbling. Taken to ER and treated with XXX.
  • 4/12 – Had altered mental status and vomiting and returned to hospital. Blood tests showed high liver enzymes

 

Continue with list until present day.