Get Ucla Form 500704 2017-2026

Filling out the UCLA Form 500704 online can streamline your healthcare process, making it easier to share important health information with your medical team. This guide provides step-by-step instructions to help you accurately complete each section of the form.

Follow the steps to effectively fill out the UCLA Form 500704 online.

1. Use the 'Get Form' button to access the UCLA Form 500704 and open it in your preferred online format.
2. Begin with the patient identification section. Fill in your MRN (medical record number) and patient name accurately to ensure your information is correctly processed.
3. In the 'Patient Health Questionnaire' section, respond to the safety questions regarding fall risks, pacemaker presence, and potential pregnancy. Make sure to select 'Yes' or 'No' for each question.
4. Document any allergies you have, including specific medication allergies if you answered 'Yes' to the allergy questions.
5. Provide your prior history of radiation therapy and chemotherapy. Include details such as the body location treated and the number of sessions you have undergone.
6. Answer the cancer history section by checking 'Yes' or 'No' for each type of cancer listed, and include additional information if applicable.
7. Complete the medical and surgical history questions honestly. Use the provided checkboxes to indicate whether you have had any of the listed conditions or surgeries.
8. For the gynecological history, female patients should fill in the relevant pregnancy and menstrual information as required.
9. Fill out the family and social history sections, checking applicable boxes for smoking and drinking habits, along with employment details.
10. Indicate your living situation and any transportation difficulties related to getting to your treatments.
11. Complete the system review section by checking 'Yes' or 'No' for each medical symptom listed.
12. Finally, review your entries for accuracy, then save your changes. You can choose to download, print, or share the completed form as needed.

Complete your UCLA Form 500704 online today to ensure your healthcare team has all the necessary information.