Get the free Medical History Statement - Connecticut, 12983.pdf

CT SI 12983 1 of 3 (8/09) Standard Insurance Company Medical Underwriting, 900 SW Fifth Avenue Portland OR 97204 Medical History Statement For Residents of: Connecticut

How to fill out medical history statement

Who needs a medical history statement?

1. Patients visiting a new healthcare provider: When visiting a new healthcare provider, it is common for them to ask for a detailed medical history statement. This statement helps the healthcare provider understand the patient's past medical conditions, surgeries, allergies, medications, and family history. By knowing the patient's medical history, healthcare providers can provide appropriate and personalized care.
2. Individuals applying for health or life insurance: Insurance companies often require applicants to fill out a medical history statement as part of the underwriting process. This statement helps the insurance company assess the applicant's health risks and determine the cost of coverage or whether they are eligible for insurance.
3. Participants in clinical trials or research studies: Researchers conducting clinical trials or studies often require participants to provide their medical history. This information helps them assess the participant's eligibility and determine if they are a suitable candidate for the trial. Additionally, a medical history statement helps researchers understand the participant's potential health risks or pre-existing conditions that may impact the study outcomes.

How to fill out a medical history statement:

1. Gather necessary information: Before starting to fill out the medical history statement, it is essential to gather all relevant medical information. This may include a list of current medications, previous surgeries or hospitalizations, past and present medical conditions, allergies, and family medical history. It is important to be thorough and accurate while providing this information.
2. Follow the instructions: The medical history statement may come with specific instructions on how to fill it out. Read these instructions carefully and ensure you understand them before proceeding. Pay attention to any specific format or order in which the information should be provided.
3. Provide personal details: Begin by providing basic personal information such as full name, date of birth, contact information, and social security number, if required. This information helps identify the person to whom the medical history statement belongs.
4. Present medical conditions: Start by listing current or present medical conditions. Include any chronic illnesses, such as diabetes or hypertension, as well as any other conditions or diseases you have been diagnosed with. It is important to mention the date of diagnosis, the treating physician, and any ongoing treatment or medications for these conditions.
5. Prior surgeries or hospitalizations: Provide a detailed account of any surgeries or hospitalizations you have undergone in the past. Include the type of procedure, the date, the name of the surgeon or hospital, and any complications, if applicable.
6. Allergies and adverse reactions: List any allergies you have, whether they are food, medication, or environmental allergies. Additionally, mention any adverse reactions or side effects you have experienced from medications or treatments in the past.
7. Family medical history: Include information about medical conditions that run in your family. This may include conditions such as heart disease, cancer, diabetes, or genetic disorders. Mention the relation to the family member affected and their age at diagnosis, if known.
8. Medications and supplements: List all medications and supplements you are currently taking, including prescription medications, over-the-counter drugs, vitamins, and herbal supplements. Include the name of the medication, dosage, frequency, and indication.
9. Additional information: The medical history statement may have blank spaces or sections for additional information. Use these spaces to provide any relevant details that were not covered in the previous sections but may be important for the healthcare provider or insurance company to know.
10. Review and sign: Once you have filled out all the necessary sections of the medical history statement, take a moment to review the information for accuracy and completeness. Make any necessary revisions or additions before signing the document. By signing the statement, you are confirming that the provided information is true and accurate to the best of your knowledge.

For pdfFiller’s FAQs

How do I execute medical history statement online?

Filling out and eSigning medical history statement is now simple. The solution allows you to change and reorganize PDF text, add fillable fields, and eSign the document. Start a free trial of pdfFiller, the best document editing solution.

How do I make edits in medical history statement without leaving Chrome?

Install the pdfFiller Google Chrome Extension in your web browser to begin editing medical history statement and other documents right from a Google search page. When you examine your documents in Chrome, you may make changes to them. With pdfFiller, you can create fillable documents and update existing PDFs from any internet-connected device.

How do I fill out medical history statement using my mobile device?

The pdfFiller mobile app makes it simple to design and fill out legal paperwork. Complete and sign medical history statement and other papers using the app. Visit pdfFiller's website to learn more about the PDF editor's features.

What is medical history statement?

The medical history statement is a document that provides information about an individual's medical history, including past illnesses, surgeries, medications, and any other relevant medical information.

Who is required to file medical history statement?

Individuals who are applying for certain types of insurance or healthcare services may be required to file a medical history statement.

How to fill out medical history statement?

Medical history statements can typically be filled out online or on paper forms provided by the insurance company or healthcare provider. The individual must provide accurate and complete information about their medical history.

What is the purpose of medical history statement?

The purpose of the medical history statement is to help insurance companies and healthcare providers assess the individual's health status and determine their eligibility for coverage or treatment.

What information must be reported on medical history statement?

Information that must be reported on a medical history statement may include past illnesses, surgeries, hospitalizations, medications, allergies, and family medical history.