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Doctor: Date: Time: revised 8/25/2015PATIENT INFORMATION FORM Please provide the following information and answer the questions below. Please note: the information you provide here is protected as.

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Social History (SH): An age appropriate review of the patient's past and current activities which may include significant information about: Marital status and/or living arrangements. Current employment. Occupational history. Use of drugs, alcohol or tobacco. Level of education. Sexual history. Other relevant social factors.

A patient information form is used to collect key patient information. This includes patient details, demographic information, and any other information regarding the patient's involvement and experience with a medical practice.

Social history paints an entire picture of the patient outside of their medical history encompassing lifestyle, risks of illness or injuries, and what make the patient unique.

The key parts of the social history can be remembered using the mnemonic LOLAS DIET: L - life- who does the patient live with? O - occupation. L - living - activities of daily living. A - alcohol consumption. S - smoking history. Di - diet. E - exercise. T - travel.

(MEH-dih-kul HIH-stuh-ree) A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests.

As we mentioned above, all social history reports should contain, to a greater or lesser extent, the same: Firstly, an identification data. Personal characteristics and data from the state of health, problems, and background, etc. Family and cohabitation data. ... Economic and employment data.

Personal information is the most basic knowledge needed to accurately complete medical forms....1. Personal Information Full and legal name. Home address. Date of birth. Emergency contact information. Phone number and email address. Preferred method of contact. Changes in marital or job status.

In medicine, a social history (abbreviated "SocHx") is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232