Get Ca Ash Initial Health Status 2012

Filling out the CA ASH Initial Health Status form is an important step in documenting your health concerns for chiropractic care. This guide will provide comprehensive instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the CA ASH Initial Health Status form.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering your personal information in the Patient Name, Address, State, Zip, and Phone sections. Ensure accuracy in spelling and contact details.
3. Fill in your Occupation and Employer information, along with their Address and City. This section helps provide context for your health concerns.
4. Complete the Subscriber Name, Subscriber ID, and Group Number fields to link your health status to the appropriate insurance plan.
5. If applicable, enter the Spouse Employer information and their City, as well as the names and contact details of your Primary Care Physician (PCP).
6. Specify your Birthdate, Primary Language, and include any additional phone numbers such as your Work Phone.
7. Indicate your Sex by marking the appropriate option. Then provide your Zip Code.
8. Identify and mark the areas where you experience pain or other symptoms on the provided diagram.
9. Describe your current health problem in detail, including how it began, and classify whether it is Work Related, Auto Related, or Not Applicable.
10. Provide the Date the problem began and describe the nature of the current complaint, rating your pain level from 0 (no pain) to 10 (unbearable pain).
11. Indicate how often your symptoms are present by selecting the appropriate percentage range.
12. Assess how much your pain has interfered with daily activities over the past week by using the provided scale.
13. Evaluate your overall health by selecting one of the options: Excellent, Very Good, Good, Fair, or Poor.
14. Report if you have had any spinal imaging (X-rays, MRI, CT scan) and provide the dates taken and areas examined.
15. Check all relevant health problems listed that apply to you, and provide details regarding any surgeries and current medications.
16. Complete the Family History section by indicating if any family members have experienced specific health issues.
17. Review the certification statement, then provide your Patient Signature and Date to verify the accuracy of the information provided.
18. Once all required fields are completed, save your changes, and choose whether to download, print, or share the filled-out form.

Complete your documents online today for a smoother healthcare experience.