Get the free Adult Patient History Form - Sellers Orthodontics

KEITH T. SELLERS, D.D.S., M.S. Welcome to our Office Orthodontic Acquaintance Form Adult Patient Information Acct.#: Address: Patient Name: Street Home Phone: Age: Birthdate: SS#: Preferred Name:

How to fill out adult patient history form

How to fill out an adult patient history form:

1. Start by entering your personal information such as your full name, date of birth, and contact details.
2. Provide information about your medical history, including any previous illnesses, surgeries, or chronic conditions you may have had. Be sure to include the dates of these occurrences.
3. Indicate any medications you are currently taking, including dosage and frequency.
4. Mention any allergies or adverse reactions you have experienced to medications, foods, or substances.
5. Provide details about your family medical history, particularly if any close relatives have had significant medical conditions.
6. Fill out the sections related to your lifestyle choices, such as smoking, alcohol consumption, exercise, and diet.
7. Answer questions regarding your mental health, such as any history of depression, anxiety, or other psychological conditions.
8. If applicable, provide information about your reproductive health, including pregnancies, childbirth, and any relevant issues.
9. Mention any recent or ongoing medical concerns or symptoms you are experiencing.
10. Sign and date the form to acknowledge that all the information provided is accurate and complete.

Who needs an adult patient history form:

1. Any individual who is visiting a new doctor or healthcare provider for the first time may be required to fill out an adult patient history form.
2. Adults who are starting a new job that requires a pre-employment health screening or physical examination may also need to complete this form.
3. Individuals seeking specialized medical treatment or undergoing a surgical procedure may be asked to provide their medical history using an adult patient history form.
4. Adults who have experienced significant changes in their health, such as the onset of a chronic condition, may be required to update their medical history using this form.

Please note that the specific requirement for an adult patient history form may vary depending on the healthcare provider, employer, or purpose for which the form is being filled out.

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