Get Hoja De Admision E Informacin

The HOJA DE ADMISION E INFORMACION is an essential form for patients seeking medical care. This guide will walk you through the steps necessary to complete the form online with clarity and ease.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient's name (NOMBRE) in the designated field. Ensure to include your first name, middle initial, and last name (APELLIDO).
3. Provide your address (DIRECCION). Include the street (Calle), apartment number (Apartamento), city (Ciudad), state (Estado), and postal code (Código Postal).
4. Enter your contact information, including your telephone number (TELÉFONO) and cellular phone number (CELULAR).
5. Fill in your date of birth (FECHA DE NACIMIENTO), using the format of month (MES), day (DÍA), and year (AÑO).
6. Indicate your sex by circling either 'M' for male or 'F' for female (SEXO).
7. Enter your age (EDAD) in the field provided.
8. Select your marital status (ESTADO CIVIL) by circling one of the following options: Single (Soltero), Married (Casado), Divorced (Divorciado), or Widowed (Viudo).
9. Provide your insurance company name (COMPAÑÍA DE SEGURO) and group number (GRUPO#).
10. If applicable, enter the policy/member number (POLIZA/NUMERO DE MIEMBRO) and the name (NOMBRE DEL ASEGURADO) and date of birth (FECHA DE NACIMIENTO DEL ASEGURADO) of the insured person.
11. Complete the employer's information by entering the employer's name (NOMBRE DEL EMPLEADOR), work address (DIRECCIÓN DEL TRABAJO), and work phone number (TELÉFONO DEL TRABAJO).
12. Indicate your job position (PUESTO) at your place of employment.
13. If you have been referred by another doctor or patient, write the name of the referring individual.
14. State the main complaint (Queja Principal) that brings you to the visit today.
15. Respond to whether your injury is the result of an accident, circling either 'Yes' or 'No' (SI o NO). If yes, provide the date of the accident.
16. List any medications, vitamins, or supplements you are currently taking.
17. Indicate any allergies to medications.
18. Provide details about your family medical history (Historial clinico familiar).
19. Answer the questions regarding your smoking and alcohol consumption habits.
20. List any history of past surgeries (Historial Quirúrgico Pasado) including type and date.
21. Provide information about any additional medical problems you have.
22. Review potential symptoms by circling pertinent areas from the review of systems (Revisión de sistemas).
23. Once all fields are complete, save your changes, and you will have the option to download, print, or share the completed form.

Complete your documents online with confidence today.