Get Filling In The Patient History Interview Form

This guide provides clear instructions for filling out the Filling In The Patient History Interview Form online. By following these steps, you can ensure that all necessary information is accurately captured for your healthcare needs.

Follow the steps to complete your patient history interview form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Begin by providing your personal information. Fill in your name, date of birth, and medical record number if applicable. This section helps to identify you in the healthcare system.
3. Next, indicate the date of your injury, height, and weight. If this form is related to a work injury, respond to the Workers Comp question with a 'Yes' or 'No'. Include your claim number and case manager's information if applicable.
4. Select your preferred method and time of contact. Provide your phone number and email address for further communication.
5. Identify your primary care physician and referring physician by filling in their names and contact details.
6. In the Present Medical History section, indicate whether you have been diagnosed with specific conditions, such as a soft tissue mass or tumor, and whether biopsies have been performed. Provide the location of the tumor or mass.
7. Detail any previous treatments you have had, including chemotherapy, radiation, or surgery. Include information on types and amounts of treatment and any side effects experienced.
8. Complete the Pain Chart by marking areas of sensation. If applicable, print the form to indicate pain levels and descriptions that may vary by location.
9. List all current medications you are taking, including prescribed and over-the-counter medicines. Note down their doses, frequency, and the name and location of your pharmacy.
10. In the Surgical/Hospitalization History section, document any surgeries or hospitalizations you've had, including the years and any complications faced.
11. Provide information about your family history regarding significant medical conditions, noting the status and age of family members wherever applicable.
12. Detail your social history, including your occupation, marital status, living situation, and any substance use such as tobacco or alcohol.
13. List any prior illnesses or injuries as well as any allergies, including reactions to medications or other substances.
14. Complete the Review of Health Systems section by checking any relevant symptoms or conditions you have experienced or are currently experiencing.
15. Finally, review your information for accuracy, sign and date the form, and ensure it is saved for your records.

Complete your Patient History Interview Form online today to ensure timely and accurate healthcare.