Es Yes Please list medications you are currently taking: Surgical History List all surgeries, location and approximate dates: Social/Dietary History Do you use or have you ever used (check all that apply): Alcohol If so, how many glasses per week do you usually drink? Wine Caffeine If so, how many cups coffee/tea and/or cans of soda a day? Cigarettes If so, how many cigarettes per day? Recreational drugs If so, please name: Has your weight changed more than 15 lbs. in the last year?.
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How to fill out the UTSW Form OBC/FRHPQ-001 online
Filling out the UTSW Form OBC/FRHPQ-001 is an essential step for individuals seeking evaluation at UT Southwestern Medical Center. This guide will provide you with clear and concise instructions to complete the form online, ensuring a smooth and efficient process.
Follow the steps to successfully complete the form online.
- Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
- Begin by entering your identifying information in the designated fields. This includes the date, marital status, phone number, home address, and age. Make sure all entries are accurate and up-to-date.
- In the menstrual history section, provide details such as the date of your most recent period, your age at first period, and whether your periods are regular. If regular, note how many days are typically between periods.
- Complete the gynecologic history section by checking all relevant tests you have undergone, such as Pap smears and mammograms. Include any abnormal Pap smear results if applicable.
- Document your contraceptive and sexual history, answering the questions about birth control issues, sexually transmitted diseases, and any discomfort during intercourse.
- For pregnancy history, fill out the chart detailing your pregnancies, outcomes, and any fertility treatments you may have undergone.
- In the medical history section, list any medical problems and allergies to medications along with current medications you are taking.
- Describe your social and dietary history, including alcohol, cigarette use, and exercise habits.
- Complete the family history section by checking relevant health issues among family members.
- Conclude by filling out any additional sections regarding fertility therapy if applicable, and ensure everything is filled out completely and correctly.
- Once you have completed the form, remember to save your changes. You may then download, print, or share the form as needed.
Start filling out the UTSW Form OBC/FRHPQ-001 online today to ensure a comprehensive evaluation at UT Southwestern Medical Center.
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Get answers to your most pressing questions about US Legal Forms API.
How do I find my medical records in Texas?
How do I get my medical records? Put your request in writing and send it to the physician's address listed on the physician's Profile on the TMB website. You can also contact the TMB to determine if a custodian of records has been reported.
What is the phone number for UT Southwestern medical records?
Phone: (214) 648-6080.
What is the phone number for UT Southwestern MyChart?
Call the MyChart Help Line at 214-648-8888.
What is the medical records number for Utsw?
For more information about medical records, please contact UT Southwestern University Hospitals and Clinics by: Phone: 214-645-3030, then choose option 1, option 1. Email: medical.records@utsouthwestern.edu.
What is the phone number for UTSW HR?
Have a question for Human Resources? We are available by phone 214-648-9810 or Email.
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