Get Pre-visit Questionnaire - Geronet - Ucla

Completing the Pre-Visit Questionnaire for GeroNet at UCLA is an important step in preparing for your medical appointment. This guide provides clear instructions and insights to help you navigate the online form effectively.

Follow the steps to complete the questionnaire accurately.

1. Press the 'Get Form' button to access the online questionnaire in your preferred digital format.
2. Begin with the date on which you completed the form, entering it in the specified format (month/day/year).
3. Input the patient's name, providing the full name as requested.
4. Fill in the home address, ensuring to include all relevant details such as street, city, and zip code.
5. Enter a contact phone number, using the appropriate format for easy access.
6. Provide the patient's date of birth, following the same month/day/year format.
7. Select the patient's gender, ensuring options are understood as they are presented.
8. Indicate who filled out the form; options include self or another person, along with their name and relationship to the patient if applicable.
9. Record the primary care doctor’s name, address, phone number, and fax number, if available.
10. Check the appropriate box regarding the intent to continue seeing the listed primary care doctor.
11. Proceed through the medical history section, checking all applicable medical conditions, and provide additional details where prompted.
12. List any past surgeries, including the types and dates of procedures undergone, in the provided sections.
13. Complete the social history section, detailing living arrangements, educational background, and employment status.
14. Address family health history by marking any relevant conditions experienced by family members.
15. Indicate whether you have advanced directives or durable power of attorney in the specified section.
16. Assess and note any general outlook on health and recent symptoms experienced, marking accordingly.
17. Finally, reflect on any specific health concerns you wish to communicate to your doctor before the visit.
18. Conclude by providing your signature and date, confirming that the information is accurate and that no proxy signatures are allowed.

Complete your Pre-Visit Questionnaire online today for a smoother appointment experience.