Get the free UPPER EXTREMITY INTAKE MEDICAL HISTORY FORM

UPPER EXTREMITY INTAKE MEDICAL HISTORY FORM 2778 N. Webb Rd / Wichita, KS 67226 / Phone (316× 6311634 ext 249 Direct faxes (316× 6311666 Name Chart# Date Age: Sex: F M Height: Weight: Dominant Hand:

How to fill out upper extremity intake medical

How to fill out upper extremity intake medical:

1. Begin by carefully reading the instructions on the intake form. Take note of any specific information or details that are required.
2. Gather all necessary personal and medical information before starting to fill out the form. This may include your full name, date of birth, contact information, and insurance details.
3. Start by providing a brief overview of your medical history. Include any previous injuries, surgeries, or medical conditions related to your upper extremities.
4. If you have any current symptoms or concerns regarding your upper extremities, make sure to describe them in detail. Mention any pain, stiffness, loss of function, or limitations you may be experiencing.
5. Indicate any recent diagnostic tests or imaging studies you have undergone related to your upper extremities. Include the dates and names of the healthcare providers who performed these tests.
6. Provide a comprehensive list of all current medications you are taking, both prescribed and over-the-counter. Include any supplements or herbal remedies as well.
7. If you have any known allergies or adverse reactions to medications or substances, make sure to mention them. This will help the healthcare provider in prescribing appropriate treatment options.
8. If you have a family history of any upper extremity conditions, such as arthritis or tendonitis, include relevant details. This familial history may be relevant in understanding your current condition or risk factors.
9. If you have seen any other healthcare providers or specialists regarding your upper extremities, provide their names and contact information. This allows for better coordination of care and ensures that all relevant medical records can be obtained if needed.
10. Finally, review the completed form to ensure all information is accurate and legible. Sign and date the form as required before submitting it to the appropriate healthcare provider.

Who needs upper extremity intake medical?

1. Individuals experiencing any issues or disorders related to their upper extremities, such as the arms, hands, and shoulders, may require an upper extremity intake medical form.
2. This may include individuals with chronic conditions, such as carpal tunnel syndrome, tennis elbow, or rotator cuff injuries.
3. People who have recently sustained an upper extremity injury, such as a fracture, dislocation, or sprain, may also need to fill out this form.
4. Individuals seeking medical treatment or consultation from orthopedic specialists, physical therapists, or occupational therapists focusing on the upper extremity may be required to complete this intake form.
5. In some cases, employers or insurance companies may request an upper extremity intake medical form to assess work-related injuries or determine eligibility for coverage.
6. It is best to consult with your healthcare provider or the facility you are seeking treatment from to determine if an upper extremity intake medical form is required in your specific situation.

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What is upper extremity intake medical?

Upper extremity intake medical is a form used to record and assess the medical history and current condition of a patient's upper extremity, including arms, shoulders, and hands.

Who is required to file upper extremity intake medical?

Patients who are seeking medical treatment or evaluation for issues related to their upper extremities are required to file upper extremity intake medical.

How to fill out upper extremity intake medical?

Upper extremity intake medical can be filled out by providing personal information, medical history, current symptoms, and any relevant medical records.

What is the purpose of upper extremity intake medical?

The purpose of upper extremity intake medical is to gather comprehensive information about a patient's upper extremity issues to assist healthcare providers in making accurate diagnoses and treatment plans.

What information must be reported on upper extremity intake medical?

Information such as personal details, medical history, current symptoms, past treatments, and any relevant imaging or test results must be reported on upper extremity intake medical.