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Kerry Sharon, MD, FAD Rachelle Cronin, PAC Mari Los, CMA, LE History & Intake Form Name: Date: Preferred Name: Occupation: What are you here for today? Past Medical History: (please circle all that

How to fill out history and intake form

How to fill out history and intake form:

1. Start by providing your personal information, such as your full name, date of birth, and contact details.
2. Indicate your medical history, including any previous illnesses, surgeries, or chronic conditions you have or have had in the past.
3. Mention any medications you are currently taking, along with dosages and frequency.
4. Provide information about any allergies or sensitivities you have, whether it's to medications, food, or other substances.
5. Fill in your family medical history, including any genetic conditions or diseases that run in your family.
6. Answer questions related to your lifestyle and habits, such as smoking or alcohol consumption, exercise routine, and diet.
7. Describe any current symptoms or complaints you have, including their duration and severity.
8. If applicable, provide details about any recent tests or medical procedures you have undergone.
9. Make sure to read the form thoroughly before signing and dating it.

Who needs a history and intake form:

1. Patients visiting a healthcare provider for the first time are typically required to fill out a history and intake form.
2. Individuals seeking specialized medical services, such as mental health counseling or physical therapy, may also need to complete these forms.
3. History and intake forms may be required before undergoing certain medical procedures or surgeries.
4. Health insurance companies and healthcare facilities often require patients to complete these forms to gather necessary information for billing and records keeping purposes.

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What is history and intake form?

History and intake form is a document that collects information about a person's medical history, current health status, and other relevant information.

Who is required to file history and intake form?

Anyone seeking medical treatment or services may be required to fill out a history and intake form.

How to fill out history and intake form?

History and intake forms can be filled out either electronically or in person, providing accurate and detailed information about one's medical history and current health concerns.

What is the purpose of history and intake form?

The purpose of history and intake form is to help healthcare providers understand a patient's health background, risk factors, and any existing conditions that may impact treatment decisions.

What information must be reported on history and intake form?

Information such as personal details, medical history, medications, allergies, current symptoms, and any previous surgeries or treatments may need to be reported on a history and intake form.