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Connecticut Children's Medical Center 282 Washington Street Hartford, CT 06106 SHORT FORM HISTORY PHYSICAL Document information in boxes indicated or note that data is detailed on the reverse side

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1. Start by carefully reading the instructions provided on the form. Make sure you understand what information is being asked for and how to properly fill it out.
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3. Fill in the sections related to your medical history. This may include questions about any pre-existing conditions, past surgeries, allergies, and current medications.
4. Be honest and provide accurate information. It is essential for healthcare providers to have a complete and accurate medical history to ensure proper diagnosis and treatment.
5. If there are any specific sections that you are unsure about or don't have the necessary information, consult a healthcare professional or contact the relevant authority for guidance.
6. Once you have filled out all the required sections, review the form to ensure it is complete and legible. Check for any errors or missing information.
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1. Individuals seeking medical care or treatment from healthcare professionals or facilities may need to fill out these forms. This includes patients visiting doctors, hospitals, clinics, or specialists.
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3. Insurance companies may request individuals to fill out these forms as part of the application or renewal process to determine eligibility and assess any pre-existing conditions.

Note: The content provided above is for illustrative purposes only. It is essential to refer to the specific instructions and guidelines provided with the actual forms to accurately complete them.

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