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2900 NE 132nd Avenue Portland, OR 97230 us.edu Phone: 5032556771 Fax: 5032515794 Patients name: DOB Date Welcome to the University of Western States clinic. Please fill out both sides of this form.

How to fill out new patient history form-intake

How to Fill out New Patient History Form-Intake:

1. Start by carefully reading the instructions provided on the form. This will give you a clear understanding of the information that needs to be provided.
2. Begin filling out the form with your personal details such as your full name, date of birth, address, and contact information. Ensure that the information is accurate and up to date.
3. Next, provide details about your medical history. This may include any past and current medical conditions, allergies, surgeries, medications, and treatments. Be as thorough as possible to ensure the healthcare provider has a complete understanding of your medical background.
4. If applicable, fill in information about your family medical history. This may include any hereditary conditions that run in your family, such as diabetes or heart disease.
5. Include details about your lifestyle and habits, such as smoking, alcohol consumption, exercise routine, and diet. These factors can play a significant role in assessing your overall health.
6. In some cases, the form may ask about your insurance information. Provide accurate details about your insurance policy, including the name of the insurance company, policy number, and any other relevant information.
7. Finally, review the completed form to ensure all the information provided is accurate and complete. Make any necessary corrections or additions before submitting it.

Who Needs New Patient History Form-Intake?

1. New patients visiting a healthcare facility, whether it is a medical clinic, hospital, or dental office, typically need to fill out a new patient history form. This form helps healthcare providers gather comprehensive information about the patient's medical background, allowing them to provide appropriate and personalized care.
2. Existing patients who have not visited the healthcare facility for an extended period may also be required to fill out a new patient history form. This ensures that the healthcare provider has the most up-to-date information about the patient's health status, changes in medications, and any new medical conditions.
3. Some medical practices or healthcare facilities may require all patients, regardless of their previous visits, to fill out a new patient history form on a periodic basis. This helps them maintain accurate and updated patient records.

For pdfFiller’s FAQs

What is new patient history form-intake?

New patient history form-intake is a document that collects important information about a patient's medical history, current medications, allergies, and other relevant details.

Who is required to file new patient history form-intake?

New patients visiting a healthcare facility for the first time are required to fill out the new patient history form-intake.

How to fill out new patient history form-intake?

To fill out the new patient history form-intake, the patient can either complete the form online or on paper provided by the healthcare facility. The patient must provide accurate and detailed information about their medical history.

What is the purpose of new patient history form-intake?

The purpose of new patient history form-intake is to gather essential information about the patient's health status, medical conditions, and any potential risks to ensure appropriate care and treatment.

What information must be reported on new patient history form-intake?

Information such as personal details, medical history, current medications, allergies, past surgeries, family medical history, and contact information must be reported on the new patient history form-intake.

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