Get Ucla 11864 2011-2026

Completing the UCLA 11864 form is essential for providing your medical history and ensuring you receive appropriate care. This guide will take you through each section of the form to help you fill it out accurately and efficiently.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to retrieve the form and open it in your preferred online editor.
2. Begin with section A, where you will provide your marital status by selecting one of the options: single, married, long-term relationship, divorced, or widowed. Then, fill in the reason for your visit, the name of the referring physician, your occupation, and your preferred phone number. Indicate whether you allow confidential voice messages.
3. Continue to section A, question 6, to provide information about your partner, if applicable, including their name and age. If you do not have a partner, select 'None.' Fill in the occupation of your partner.
4. In section B, provide your menstrual history. Indicate your age at the first period, the regularity of your menstrual cycles, the duration of bleeding, and any occurrences of spotting between periods or after intercourse. Document the date of your last menstrual period and any associated pain.
5. Section C involves your pregnancy history. Select if you have never been pregnant, and if applicable, detail your obstetrical history including any abortions or ectopic pregnancies along with relevant information.
6. Move to section D, birth control history, and specify the current birth control methods you are using.
7. In section E, provide information about your sexual history, including whether you have a sexual partner and if there are any concerns you'd like to discuss with your doctor.
8. Fill out section F to list any past obstetrical or gynecological surgeries you have undergone, checking the applicable boxes and providing years of the surgeries.
9. In section G, disclose any past surgical history that is not specific to obstetrics or gynecology.
10. For section H, provide the date of your last pap smear and mammogram, and indicate any previous abnormal results along with treatments received.
11. Section I will ask you to check any past medical history conditions that apply to you, ensuring an accurate record.
12. In section J, list the current medications you are taking, including the dosages and frequency of use.
13. Complete section K by answering questions about smoking, alcohol, drug use, and your exercise habits.
14. Section L addresses any drug allergies you may have; please list them if applicable.
15. For section M, review your family's medical history and check any relevant conditions, naming affected relatives if necessary.
16. In section N, respond to any recent symptoms you may have experienced, along with any other specified symptoms.
17. If applicable, complete section O regarding genetic screening related to pregnancy, detailing any history or results as requested.
18. After finishing the form, review your entries for accuracy. Then, if needed, save your changes, download, print, or share the form as required.

Start completing your UCLA 11864 form online today for a streamlined submission process.