Get Patient Screening Form

Filling out the Patient Screening Form online is a straightforward process designed to gather essential information for your medical care. This guide provides detailed steps to help you complete each section effectively and accurately.

Follow the steps to complete the Patient Screening Form online.

1. Click ‘Get Form’ button to access the Patient Screening Form online and open it in your preferred document viewer.
2. Begin by filling in your name and date of birth in the designated fields. Make sure to provide your full name as it appears on your identification documents.
3. Next, enter your Social Security Number in the provided space. This information is crucial for identification and insurance purposes.
4. Choose your marital status by selecting one of the options: Single, Married, Divorced, or Widowed.
5. Indicate your ethnicity from the list provided. This section may include options like Caucasian, African American, Hispanic, Asian, and others.
6. Fill in your home address, including city, state, and zip code. Ensure that this information is current to avoid any delays in communication.
7. Provide your phone numbers. Indicate which phone number you prefer as your primary contact method, selecting from home, cell, or work.
8. Enter your email address and choose your preferred method of contact—either phone or email.
9. Complete the employment section by entering your employer’s name, your occupation, or if retired, your previous occupation.
10. Identify your primary care physician and preferred pharmacy in the corresponding fields.
11. Indicate whether you are a resident of a nursing facility. If yes, provide the name of the facility.
12. If someone referred you to the practice, provide their name in the referral section.
13. Fill out the emergency contact information. Include the names and phone numbers of your preferred contacts and their relationship to you.
14. For insurance information, enter details about your primary and secondary insurance, including carrier, subscriber number, group number, and name of the insured.
15. List all current medications along with dosage and frequency in the medications section. Include any over-the-counter medications, vitamins, or supplements.
16. In the allergies section, indicate if you have any medication or food allergies, providing details if applicable.
17. Mark any current medical problems on the checklist provided, ensuring that you accurately indicate your health status.
18. Detail any previous surgeries, particularly cardiac procedures, if applicable, and provide relevant dates and device information.
19. Complete the family history section by answering questions about your parents' health and noting any immediate family medical conditions.
20. In the social history section, provide information on your exercise habits, tobacco use, and alcohol consumption.
21. Review the office policies, ensuring that you understand the financial and insurance policies as outlined.
22. Finally, sign and date the form, certifying that all information provided is truthful and complete.
23. Once you have filled out the form, save your changes, and you can choose to download, print, or share the form as needed.

Get started on completing your Patient Screening Form online today.