This is a suggested format, a more complete fill in version is forthcoming

Symptoms : ( in chronological order , followed by treatments)

Tests : (MRI, Blood work, etc.)

Medications listing : (including actions/reactions and dates of use)

Past History: Accidents, surgeries, hospitalizations

Family history : Dad, Mom, Grandparents, Siblings, other relatives

Has anyone has a similar situation

Social concerns  (such as stresses and environmental exposures)

Copyright Center of Health 2006