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SOUTHERN TIER ARTHRITIS & RHEUMATISM JAMES C. HANDBALL, M.D. JOSEPHINE RAAF, APC DOUGLAS E. TANNER, PAC MEDICAL HISTORY FORM NAME: DATE: DATE OF BIRTH: ILLNESS (other than childhood diseases): SURGERIES:

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How to fill out medical history form

01

Start by providing your personal information such as your name, date of birth, address, and contact details.

02

Next, fill in your medical history including any past or current medical conditions, surgeries, allergies, and medications you are currently taking.

03

Include information about your family medical history, such as any hereditary diseases or conditions that run in your family.

04

List any vaccines you have received and the dates they were administered.

05

Provide information about your lifestyle habits such as smoking, alcohol consumption, and exercise routine.

06

If applicable, mention any previous hospitalizations or emergency room visits.

07

Finally, sign and date the form to validate the information provided.

Who needs medical history form?

01

Anyone visiting a healthcare provider or seeking medical treatment needs to fill out a medical history form.

02

This form is essential for new patients, as it helps the healthcare provider understand the patient's medical background.

03

Existing patients may also be required to update their medical history periodically.

04

Medical history forms are necessary for both routine check-ups and specialized medical procedures.

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What is medical history form?

A medical history form is a document used to collect information about an individual's past and current health conditions, medical treatments, and family medical history.

Who is required to file medical history form?

Typically, patients seeking medical care, insurance applicants, or individuals undergoing certain medical procedures are required to file a medical history form.

How to fill out medical history form?

To fill out a medical history form, individuals should provide accurate information regarding their personal health history, medications, allergies, surgeries, and any relevant family medical history.

What is the purpose of medical history form?

The purpose of a medical history form is to gather essential information that helps healthcare providers make informed medical decisions and tailor treatment plans for the patient.

What information must be reported on medical history form?

Information that must be reported includes personal health conditions, medications, allergies, surgical history, immunizations, and family health history.

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