Get the free Medical History Form - siue

This form is used to collect personal and medical history information from patients for the Southern Illinois University Edwardsville Health Service.

How to fill out medical history form

How to fill out Medical History Form

1. Start with personal information: Fill in your name, date of birth, and contact information.
2. Provide emergency contact details: Include the name and phone number of a person to contact in case of an emergency.
3. List current medications: Write down any prescription and over-the-counter medications you are currently taking, including dosages.
4. Document medical history: Include any past surgeries, chronic illnesses, and relevant medical conditions.
5. Detail allergies: Note any known allergies to medications, foods, or other substances.
6. Include family medical history: Provide information about any hereditary conditions or illnesses in your family.
7. Fill in lifestyle information: Add details about lifestyle choices such as smoking, alcohol consumption, and exercise habits.
8. Review and sign: Go over the form for accuracy and completeness, then sign and date it.

Who needs Medical History Form?

1. Individuals applying for medical treatment or a physical exam.
2. Patients undergoing specific medical procedures or surgeries.
3. People enrolling in health insurance plans that require health assessments.
4. Those seeking a new healthcare provider who requires a medical background.

People Also Ask about

How do I write my own medical history?

The medical record contains valuable information about a patient's medical history and individual clinical interactions. It is also a legal document that can serve as evidence of the care provided and discussions with the patient.

How to write the medical history?

You could start with: Your name, birth date, blood type, and emergency contact information. Date of last physical. Dates and results of tests and screenings. Major illnesses and surgeries, with dates. A list of your medicines and supplements, the dosages, and how long you've taken them. Any allergies. Any chronic diseases.

How to fill out a medical records request form?

How to fill out a health or medical record release form Patient information. Whose health records do you want? Clinic, hospital, care provider. Date of Services. Information to be released. Receiving party or destination of records. Purpose of release. Expiration date or duration of consent. Release instructions.

How to fill a medical history form?

Some of the issues that can be covered in a health history form include: The patient's health conditions and illnesses. Contact information for the patient's primary health care provider and/or any specialists coordinating specific medical treatment. Current medications that the patient is taking.

What information should be included on a medical history form?

A comprehensive history intake includes the patient's medical history, past surgical history, family medical history, social history, allergies, and medications.

How to fill out a medical history form?

The basic structure of the history is as follows: Presenting complaint (PC) History of presenting complaint (HPC) Past medical history (PMHx) Drug history (DHx) Family history (FHx) Social history (SHx) Systems review (SR) Ideas, concerns, expectations (ICE)

How do I write a medical history?

This article explains how. Step 1: Include the important details of your current problem. Timing – When did your problem start? Step 2: Share your past medical history. List all your past medical problems and surgeries. Step 3: Include your social history. Step 4: Write out your questions and expectations.

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What is Medical History Form?

A Medical History Form is a document used to collect information about a patient's past medical conditions, treatments, medications, and family medical history.

Who is required to file Medical History Form?

Patients seeking medical treatment or evaluation are typically required to file a Medical History Form to provide healthcare providers with necessary background information.

How to fill out Medical History Form?

To fill out a Medical History Form, patients should provide accurate and complete information regarding their personal medical history, including past illnesses, surgeries, allergies, medications, and family health issues.

What is the purpose of Medical History Form?

The purpose of a Medical History Form is to help healthcare providers understand a patient's health background, allowing them to make informed decisions about diagnosis, treatment, and care.

What information must be reported on Medical History Form?

The information that must be reported includes personal health information, previous medical conditions, surgeries, medications, allergies, immunization history, and family medical history.