Get Patient Information Sheet

Filling out the Patient Information Sheet online is a crucial step in your healthcare journey, providing essential information for your medical team. This guide will walk you through each component of the form, ensuring that you can complete it accurately and efficiently.

Follow the steps to complete the Patient Information Sheet online.

1. Click the ‘Get Form’ button to access the Patient Information Sheet and open it in your preferred editing tool.
2. Begin with the patient information section. Fill in your name, date of birth, gender, age, height, weight, and body mass index (BMI). Include your current address, city, state, and zip code.
3. Provide primary and secondary phone numbers, and include your email address for contact.
4. Enter your Social Security Number and select your preferred language for communication.
5. Indicate your citizenship status by choosing 'Yes' or 'No' and specify if you are a legal resident if applicable.
6. Answer the ethnicity question as accurately as possible to aid in your healthcare.
7. If you are on dialysis, specify 'Yes' or 'No' and provide the date when you started dialysis. If applicable, describe your reason for considering a transplant.
8. Fill in the information about your dialysis center, including address and phone number, and specify the type of dialysis treatment you undergo.
9. Disclose any history of drug abuse if applicable, including when you stopped and whether you completed a drug rehabilitation program.
10. List any allergens you have.
11. Document any recent hospitalizations within the last year, detailing the dates, locations, and reasons for each visit.
12. Enter your surgical history, listing any surgeries you have undergone along with the corresponding dates.
13. Answer questions regarding kidney failure causes and any previous transplants, specifying the date and type of organ if applicable.
14. Indicate your mobility aids if any (e.g., walk, cane, wheelchair) and if you reside in a nursing home.
15. Complete the health information review of systems by responding 'Yes' or 'No' to the list of provided health conditions.
16. Provide insurance information for primary and secondary insurance, including carrier name, policy numbers, and subscriber details.
17. Fill out physician information by providing your nephrologist's and primary care physician's names, addresses, and phone numbers.
18. Finally, confirm your appointment information with the assigned coordinator, date, and time.
19. After completing all sections, review your entries for accuracy and clarity. You may then save changes, download, print, or share the completed form as needed.

Complete your documents online to ensure your healthcare experience is smooth and efficient.