Get Patient History Form For Tbi

Filling out the Patient History Form For Tbi online is a straightforward process that allows users to provide essential information regarding traumatic brain injury. This guide will walk you through each step, ensuring you complete the form efficiently and accurately.

Follow the steps to fill out the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your name in the designated fields: first name, middle initial, and last name. Ensure accuracy as this information is vital for identification.
3. Fill in today's date and your home address, including city, state, and zip code. This section helps establish your contact information.
4. Provide your date of birth and age. This information is necessary for medical records.
5. Enter your social security number, email address, and occupation. Make sure your email address is correct to receive any correspondence promptly.
6. Indicate your phone numbers: home, cell, and work. This ensures the office can reach you as needed.
7. In the primary caregiver section, fill in the name and relationship to the patient. This helps in understanding the support system in place.
8. Provide the drive time to the office, which can assist in scheduling appointments.
9. Respond to the questions regarding living arrangements and the ability of the caregiver to accompany the patient to visits by selecting ‘Yes’ or ‘No.’ If applicable, describe the living arrangements.
10. In the diagnosis/patient care section, specify the date of the traumatic brain injury and list the physician who diagnosed it, including their contact information.
11. List your general medical history, including current medical conditions and allergies. This provides comprehensive background information to the healthcare providers.
12. Detail all current medications and dosages, including how many pills are taken per day and when the medication regimen started.
13. In the specific medical history section, indicate ‘Yes’ or ‘No’ for the listed conditions. Be thorough to ensure a complete medical evaluation.
14. After completing all sections, review your information for accuracy. You can then save changes, download a copy, or print the form.
15. To submit the form, click the Submit Form button, use your email application to send it to the specified address, or fax the document as directed.

Complete your Patient History Form For Tbi online today to ensure timely and accurate medical evaluation.