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Revised March 2013 MEDICAL HISTORY FORM NAME Date of Birth This form must be completed and signed, prior to the physical examination, for review by examining practitioner. Explain Yes answers below

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How to fill out this form must be:

1. Start by carefully reading the instructions provided on the form. This will give you an understanding of the information that needs to be provided and any specific guidelines to follow.
2. Begin filling out the form by entering your personal details accurately. This may include your full name, address, contact information, and any other required identification details.
3. Move on to the specific sections of the form, providing the requested information in a clear and concise manner. It is important to double-check the accuracy of the details before moving to the next section.
4. If there are any checkboxes or multiple-choice options, make sure to select the appropriate choices based on your situation. Pay attention to any instructions or specifications provided.
5. In case additional documents or attachments are required, make sure to include them with the form. Carefully follow any instructions on how to provide these attachments, such as by stapling them or placing them in a separate envelope.
6. Once all the required fields have been completed, review the form thoroughly to ensure all the information provided is accurate and complete. Correct any errors or omissions before submitting.
7. Finally, sign and date the form as required. This signature serves as an acknowledgment of your agreement to the information provided and any legal consequences that may accompany it.

Who needs this form must be:

1. Individuals applying for a specific program, service, or procedure may be required to fill out this form. It is important for them to accurately provide the necessary information to ensure a smooth processing of their application.
2. Employers or organizations may require employees or members to complete this form for administrative purposes, such as record-keeping or compliance.
3. Government agencies or institutions may utilize this form to gather essential data required for regulatory, statistical, or legal reasons.

Overall, anyone who is required to provide specific information in a standardized format would need to fill out this form. It is important to ensure accuracy, completeness, and adherence to any guidelines provided to avoid delays or complications in the processing of the form.

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