Get the free Patient History Form - Texas Tech Physicians

TTU HSC School of Medicine Department of Surgery Lubbock, TX Patient History Form Page 1 of 2 Patient Names: MAN: DOB: 1. Who is your primary care Physician? 2. Who referred you to our physician?

How to fill out patient history form

1. To fill out a patient history form, start by reviewing the instructions provided. This will give you an overview of what information is required and how to properly fill out the form.
2. Begin by entering your personal details such as your full name, date of birth, and contact information. This is important for identification purposes and communication.
3. Provide your medical history by indicating any past or current medical conditions, surgeries, allergies, and medications you are taking. This information helps healthcare professionals understand your medical background and make informed decisions about your care.
4. Make sure to include information about any chronic diseases, such as diabetes or hypertension, as well as any significant past illnesses or injuries. This will aid in creating a comprehensive medical profile.
5. Don't forget to mention any family history of diseases, as it can provide valuable insights into potential genetic predispositions or hereditary conditions.
6. If you have been hospitalized previously, indicate the dates, reasons, and locations of your hospital stays.
7. Include any information regarding your lifestyle habits such as smoking, alcohol consumption, diet, and exercise. These details can have an impact on your overall health and may be relevant for treatment plans.
8. It is essential to be honest and thorough when filling out the form. Providing accurate and complete information ensures that healthcare professionals can make well-informed decisions and provide appropriate care.

Who needs a patient history form?

1. Patients visiting a healthcare facility for the first time often need to fill out a patient history form. These forms allow healthcare professionals to gather valuable information about the patient's medical background, family history, and current health status.
2. Individuals seeking specialized medical care or undergoing specific procedures or surgeries may also be required to complete a patient history form. This ensures that the healthcare provider has a detailed understanding of the patient's condition and can develop an appropriate care plan.
3. Patient history forms are important for both new and returning patients, as they serve as a comprehensive record of a person's health history. This information is valuable for ongoing healthcare management, tracking progress, and assessing any changes in the patient's condition over time.

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