Get Initial Patient Visit Form General Information

Completing the Initial Patient Visit Form General Information online is a straightforward process that helps facilitate your visit. This guide will walk you through each section to ensure that your information is accurately captured.

Follow the steps to fill out your form with ease:

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. In the patient name field, enter your full name as it appears on your identification.
3. Fill in your date of birth accurately in the designated section.
4. Provide the name and phone number of your primary care physician in the appropriate fields.
5. Indicate whether you are an Alabama native by selecting 'Y' for yes or 'N' for no.
6. If you selected 'N', specify your state or country of origin.
7. Answer if you were referred to the UAB Breast Clinic by choosing the relevant option.
8. If referred, specify the person or connection who referred you.
9. Indicate whether you are interested in support groups or counseling services by marking 'Y' or 'N'.
10. Proceed to fill out the breast history section, including the date of diagnosis and any previous treatments.
11. Complete the menstrual history section with accuracy regarding your reproductive health.
12. Fill in the family history questions related to genetic predispositions and cancer history.
13. List any known allergies to medications in the designated area under past history.
14. Review the review of body systems section to indicate any current health issues or symptoms.
15. Rate your current pain level on a scale from 0 to 10.
16. Finally, ensure you sign the form and provide the initials of the medical doctor.

Complete your INITIAL PATIENT VISIT FORM online today to ensure a smooth and efficient patient experience.