Get Medical History Form

Completing the Medical History Form accurately is crucial for creating a comprehensive medical record. This guide will assist you in filling out the form effectively without any confusion.

Follow the steps to complete the Medical History Form online:

1. Click ‘Get Form’ button to access the Medical History Form and open it in your preferred document editor.
2. Begin by entering your full name in the designated field. This ensures proper identification in your medical records.
3. Indicate if you are currently pregnant by selecting 'Y' for yes or 'N' for no.
4. Fill in your age and the date on which you are completing the form.
5. Provide your Social Security number and date of birth to verify your identity.
6. Indicate whether you are right or left-handed by selecting the appropriate option.
7. Document the date of any accident or injury you are reporting.
8. Supply your contact numbers, including home, cell, and work phone numbers. Enter these in the respective fields.
9. List any drug allergies you may have.
10. Fill in your height and weight for a better understanding of your general health.
11. Clearly state the reason for your visit. Be as specific as possible.
12. In the following section, describe the current orthopaedic problem including duration, factors that worsen the condition, and any relief measures.
13. Indicate any previous treatments or procedures you have had by circling all that apply—physical therapy, cortisone injections, or specific medications.
14. List all current medications you are taking in the allocated space.
15. Chronologically document any past surgeries you have undergone.
16. For diagnostic studies related to your current condition, list the types and the dates those studies were performed.
17. Provide your family medical history by listing any relevant medical conditions affecting your immediate family members.
18. Fill out the social history section, checking the appropriate boxes and providing additional details as necessary.
19. In the general history section, mark any relevant health issues that apply to you.
20. Continue filling out the rest of the health history sections as they pertain to you.
21. Describe your current employment or occupation, noting if the injury is work-related.
22. Provide the name and contact information of the physician who referred you.
23. Finally, remember to sign and date the form before submission.
24. You may choose to save changes, download, print, or share the completed form as needed.

Start filling out your Medical History Form online today for a thorough record.