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FOR SCIENCES STAFF ONLY DATA MISSING 600 South 43rd Street, Philadelphia, PA 19104-4495 Phone: 215-596-8980 Fax: 215-596-7621 DATE COMPLETE: MEDICAL HISTORY QUESTIONNAIRE 2012-2013 INSTRUCTIONS AND

How to fill out medical history questionnaire form

How to fill out a medical history questionnaire form:

1. Start by carefully reading the instructions or guidelines provided with the form.
2. Begin by providing your personal information, such as your full name, date of birth, and contact details.
3. Move on to answer questions about your medical history, including any previous illnesses, surgeries, or chronic conditions you may have experienced.
4. Answer questions about your family's medical history, particularly if there are any hereditary diseases or conditions that run in your family.
5. Make sure to provide accurate information regarding your current medications, allergies, and any adverse reactions you have had to certain drugs or treatments.
6. If the form includes questions about your lifestyle habits, such as smoking or alcohol consumption, answer truthfully.
7. Lastly, review the completed form to ensure all the necessary sections have been filled out correctly and legibly.

Who needs a medical history questionnaire form:

1. Individuals seeking medical treatment or healthcare services from a new healthcare provider may be asked to fill out a medical history questionnaire form.
2. Patients who are undergoing a surgical procedure or planning to participate in a clinical trial may also be required to complete this form.
3. Additionally, individuals applying for health insurance or disability benefits may be asked to provide their medical history through a questionnaire form.

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What is medical history questionnaire form?

A medical history questionnaire form is a document that collects information about an individual's past and current medical conditions, medications, allergies, and family medical history. It is used by healthcare providers to assess a patient's health status and make informed medical decisions.

Who is required to file medical history questionnaire form?

Any individual seeking healthcare services or treatment is typically required to fill out a medical history questionnaire form. This includes new patients, existing patients, and individuals undergoing specific medical procedures or treatments.

How to fill out medical history questionnaire form?

To fill out a medical history questionnaire form, individuals need to provide accurate and complete information about their medical history, including any chronic illnesses, surgeries, medications, allergies, and family medical history. They should answer all the questions on the form truthfully and to the best of their knowledge.

What is the purpose of medical history questionnaire form?

The purpose of a medical history questionnaire form is to gather comprehensive information about an individual's health history. This information helps healthcare providers understand the patient's medical background, identify potential risk factors or contraindications, and provide optimal and personalized healthcare services.

What information must be reported on medical history questionnaire form?

A medical history questionnaire form typically requires information such as personal identifying details, medical conditions, medications, allergies, surgical history, family medical history, lifestyle habits, and any specific symptoms or concerns the individual may have.

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