Get Patient History Form History Of Present Illness

Completing the Patient History Form HISTORY OF PRESENT ILLNESS online is an important step in ensuring you receive the appropriate care. This guide will help you navigate the form effectively, providing instructions for each section to ensure that your information is accurately captured.

Follow the steps to successfully complete your Patient History Form

1. Click ‘Get Form’ button to access the Patient History Form and open it in your web browser.
2. Fill in your personal details such as your name, date of birth, age, gender, and the date of form completion at the top of the form.
3. Indicate your marital status and list the ages of any children you may have in the designated fields.
4. State who referred you to the clinic to provide context for your visit.
5. In the HISTORY OF PRESENT ILLNESS section, clearly specify the condition you are seeking help for today.
6. Describe your symptoms in detail, including how they feel and any relevant experiences related to them.
7. Specify the side of your body where the condition occurs by selecting 'N/A', 'Right', 'Left', or 'Both'.
8. Indicate the condition's onset date and whether it is chronic, a new injury, or occurred for no apparent reason.
9. Answer whether the condition is related to an accident or a fall by providing relevant details.
10. Document any previous diagnostic imaging you have had for your condition, such as MRI or X-rays.
11. List any doctors or clinicians you have consulted regarding this condition and detail the treatments you have received.
12. Indicate if you have undergone physical therapy for this condition.
13. State if you have had surgery related to this condition and provide relevant details.
14. Describe any everyday, work, or recreational activities you are finding difficult due to your symptoms.
15. Answer whether your symptoms are constant.
16. Mark whether your symptoms are getting better, getting worse, or remaining the same.
17. Circle activities that exacerbate your symptoms from the provided list.
18. Circle activities that alleviate your symptoms from the provided list.
19. Circle the worst intensity of your symptoms experienced in the past week using the 0 to 10 scale.
20. Circle the current intensity of your symptoms using the 0 to 10 scale.
21. Circle the best intensity your symptoms were at in the past week.
22. Shade or mark the areas on your body where you experience your symptoms.
23. Rate your general health in the provided section.
24. Describe your living situation, noting if you live alone, with family, or in another arrangement.
25. Provide information about your occupation and any hobbies you engage in.
26. Indicate whether you have fallen in the past year and if you fall often.
27. Circle all applicable health issues listed in the medical history section.
28. List and date all surgeries you have had.
29. List and date any hospitalizations you have experienced.
30. Provide any additional comments regarding your past medical history.
31. Document your current medications, including type, dosage, purpose, and frequency.
32. Add any final comments that may be relevant for the healthcare provider.
33. Sign and date the form, ensuring the accuracy and completeness of your information.
34. Once you have completed the form, save your changes, and select your preferred option to download, print, or share the form.

Ensure your medical records are accurate and complete by filling out your Patient History Form online today.