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Concussion Management Center of Central PA, LLC Hollidaysburg, PA Name: Date of Injury: School: Football Basketball Soccer Wrestling Cheerleading Softball Sport: Hockey Gymnastics Volleyball Across
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How to fill out initial intake form
How to fill out initial intake form:
01
Start by providing your personal information, such as your full name, date of birth, and contact details.
02
Proceed to fill in your medical history, including any past illnesses, surgeries, or chronic conditions you may have.
03
Specify any medications you are currently taking, including the dosage and frequency.
04
Mention any allergies or adverse reactions you have experienced to medications or substances in the past.
05
Provide information about your lifestyle habits, such as smoking, alcohol consumption, and exercise routine.
06
Indicate your family medical history, including any hereditary conditions or diseases that run in your family.
07
Answer questions regarding your current symptoms or reasons for seeking medical attention.
08
If applicable, describe any previous treatments or therapies you have undergone for your condition.
09
Lastly, review the form for accuracy and completeness before submitting it to the healthcare provider.
Who needs initial intake form:
01
New patients visiting a healthcare facility for the first time are typically required to fill out an initial intake form.
02
Individuals starting a new program or seeking a consultation in a counseling or therapy setting.
03
Patients being admitted to a hospital or healthcare institution may also be asked to fill out an initial intake form to gather necessary information for their care.
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What is initial intake form?
The initial intake form is a document used to collect basic information about a new client or case.
Who is required to file initial intake form?
Attorneys, law firms, or legal representatives are typically required to file an initial intake form.
How to fill out initial intake form?
The initial intake form can be filled out by providing requested information such as client name, contact information, case details, etc.
What is the purpose of initial intake form?
The purpose of the initial intake form is to gather necessary information to assess the client's needs and determine if the representation is appropriate.
What information must be reported on initial intake form?
Information such as client's name, contact information, case details, legal issues, etc. must be reported on the initial intake form.
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