Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date at the top of the form. This should be the date you are filling out the form.
3. Fill in the patient’s full name and date of birth. This information is crucial for identifying the individual’s health records.
4. If someone other than the patient is completing the form, indicate their name and relationship to the patient.
5. If applicable, provide the name of a legal guardian. Also, state the marital status of the patient.
6. Enter emergency contact details, including their name, relationship to the patient, and telephone number.
7. Record the date of the patient’s last medical examination.
8. Outline any current medical issues the patient is experiencing. Be as detailed as necessary to provide accurate health information.
9. Respond to questions regarding perinatal or developmental abnormalities. If there are any, explain on the back of the form.
10. Indicate whether the patient is currently taking any medications, both prescription and non-prescription. If yes, list the names, dosages, and start dates of these medications.
11. Address any allergies the patient may have. If they have allergies, please provide a detailed list.
12. Note if the patient has received any psychological or psychiatric treatment, and provide additional details if applicable.
13. If the patient has a history of inpatient treatment for mental health or substance abuse issues, list the facilities, dates, and duration of each stay.
14. Describe the reasons the patient is currently seeking help.
15. Indicate the patient’s smoking habits and the number of cigarettes smoked daily, if applicable.
16. Record the average weekly alcohol consumption in drinks.
17. If the patient has faced any problems related to alcohol consumption, such as legal or health issues, provide an explanation.
18. Mark any symptoms the patient has experienced from the list provided, selecting 'Yes' or 'No' for each.
19. Finally, review the completed form for accuracy, then save changes, download, print, or share the form as necessary.

Complete your documents online to ensure effective management of your health information.