Get the free MEDICAL HISTORY QUESTIONNAIRE - iwmfcom

Please complete and return in enclosed envelope, or to Jennifer Sherman, DanaFarber Cancer Institute, 44 Kinney St, D1B30, Boston, MA 02115. MEDICAL HISTORY QUESTIONNAIRE Name Date of Birth: / / Sex:

How to fill out medical history questionnaire

How to fill out a medical history questionnaire:

1. Read the instructions carefully: Start by thoroughly reading the questionnaire and any accompanying instructions to understand what information is being asked for and how to provide it accurately.
2. Gather necessary documents: Before filling out the questionnaire, gather any relevant documents that might be required, such as prior medical records, a list of medications or allergies, and contact information for your healthcare providers.
3. Provide personal information: The questionnaire may ask for basic personal information such as your name, date of birth, and contact details. Fill in this information accurately.
4. Medical conditions: The questionnaire will likely ask about any current or past medical conditions you have been diagnosed with. Be specific and provide details about the conditions, including any treatments or medications you have received for them.
5. Medications and allergies: List all the medications you are currently taking, including prescription drugs, over-the-counter medications, and supplements. Include any known allergies to medications or other substances.
6. Family medical history: There may be a section that asks about the medical history of your family members, particularly close relatives such as parents, siblings, and grandparents. Provide any information you are aware of, including any genetic conditions or diseases that run in your family.
7. Surgical history: If you have had any surgeries in the past, indicate the type of surgeries, dates, and any complications or outcomes.
8. Lifestyle habits: Some questionnaires might inquire about your lifestyle habits such as smoking, alcohol consumption, exercise routine, and dietary preferences. Be honest and provide accurate information to help healthcare professionals assess your overall health status.
9. Additional information: The questionnaire may have sections where you can provide additional information or elaborate on any health concerns or symptoms you are experiencing. Use this opportunity to provide any relevant details that you think might be important for your healthcare provider to know.

Who needs a medical history questionnaire?

1. New patients: When visiting a new healthcare provider for the first time, they will typically require you to fill out a medical history questionnaire. This helps them understand your medical background and identify any potential risks or concerns.
2. Existing patients: Even if you are an existing patient at a healthcare facility, you may be asked to update your medical history periodically. This ensures that your healthcare provider has the most up-to-date information about your health status and can provide appropriate care.
3. Prior to medical procedures: Before undergoing surgeries, diagnostic tests, or procedures, healthcare providers often ask patients to complete a medical history questionnaire. This helps them assess any potential risks or complications associated with the procedure based on your existing health conditions.
4. Emergencies: When seeking emergency medical care, filling out a medical history questionnaire may not always be feasible. However, it is still crucial to provide any relevant medical information to the healthcare professionals treating you, as it can significantly impact the course of treatment and ensure your safety.

Ultimately, medical history questionnaires are essential tools used to gather comprehensive information about an individual's health status, allowing healthcare providers to make informed decisions and provide appropriate care.

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What is medical history questionnaire?

A medical history questionnaire is a form that collects information about an individual's past and current medical conditions, treatments, and medications.

Who is required to file medical history questionnaire?

Individuals who are seeking medical treatment or care from a healthcare provider are typically required to fill out a medical history questionnaire.

How to fill out medical history questionnaire?

To fill out a medical history questionnaire, individuals should provide accurate and detailed information about their medical history, including any existing conditions, past surgeries, and current medications.

What is the purpose of medical history questionnaire?

The purpose of a medical history questionnaire is to help healthcare providers assess an individual's health status, identify potential risks, and make informed medical decisions.

What information must be reported on medical history questionnaire?

Information such as current medical conditions, past surgeries, allergies, medications, family medical history, and lifestyle habits should be reported on a medical history questionnaire.