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Patient Name: Date of Birth: Past Medical History: (please circle all that apply) Anxiety Depression Arthritis Diabetes Asthma End Stage Renal Disease Atrial fibrillation HERD Bone Marrow Transplantation
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How to fill out past medical history:

01
Start by gathering all relevant medical documents, such as previous medical records, test results, and medication history.
02
Begin with personal information, including your full name, date of birth, contact information, and any updates in your medical records.
03
Next, list any chronic or significant medical conditions you have been diagnosed with in the past, such as diabetes, asthma, or high blood pressure.
04
Provide details about any surgeries or hospitalizations you have undergone, including the reason, date, and outcome of the procedures.
05
Include information about any allergies you have, including medication, food, or environmental allergies.
06
Document any current medications you are taking, including the name, dosage, and frequency of use.
07
Mention any significant family medical history, such as a history of heart disease, cancer, or genetic disorders.
08
Don't forget to mention any lifestyle factors that may impact your health, such as smoking, alcohol consumption, or drug use.
09
Make sure to update your past medical history regularly as new information becomes available, such as new diagnoses or changes in medications.
10
Everyone, including patients, healthcare providers, and medical professionals, needs past medical history to get a comprehensive understanding of an individual's health status and to provide appropriate medical care and treatment. By having access to past medical history, healthcare providers can make informed decisions, avoid potential conflicts with medications or treatments, and anticipate potential complications. Additionally, individuals themselves can use their past medical history to track their health progress, make informed lifestyle choices, and communicate effectively with healthcare professionals.
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Past medical history refers to a person's medical experiences and conditions in the past.
Individuals are typically required to provide their past medical history, especially when seeking healthcare services.
Past medical history can be filled out by providing information about previous illnesses, surgeries, medications, allergies, and family medical history.
The purpose of past medical history is to help healthcare providers understand a person's health background and make informed decisions about their care.
Information such as past illnesses, surgeries, medications, allergies, family medical history, and any other relevant health conditions should be reported on past medical history forms.
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