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UAB Department of Genetics
Cytogenetics Laboratory
Phone: (205) 934955511/28/22MedicalRecord#Fax: (205) 9341078PATIENT HISTORY AND REQUEST FORM FOR CANCER PHYLOGENETIC ANALYSIS
Patient Name:Date of
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How to fill out patient history and request
How to fill out patient history and request
01
Collect personal information of the patient including name, age, gender, and contact details.
02
Record the patient's medical history, including any past illnesses, surgeries, medications, and allergies.
03
Document the patient's family medical history to identify any hereditary conditions.
04
Include information about the patient's lifestyle habits such as smoking, alcohol consumption, and exercise routine.
05
Record the reason for the patient visit, including any symptoms or concerns they may have.
06
Ensure all information is accurate and up to date.
Who needs patient history and request?
01
Doctors
02
Nurses
03
Medical specialists
04
Healthcare providers
05
Insurance companies
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What is patient history and request?
Patient history and request is a document that provides information about a patient's medical history, current health status, and treatment requests.
Who is required to file patient history and request?
Healthcare providers, such as doctors, nurses, and medical facilities, are required to file patient history and request.
How to fill out patient history and request?
Patient history and request can be filled out by healthcare providers using electronic medical record systems or paper forms.
What is the purpose of patient history and request?
The purpose of patient history and request is to ensure that healthcare providers have accurate and up-to-date information about a patient's medical history and treatment preferences.
What information must be reported on patient history and request?
Patient history and request should include details of past illnesses, surgeries, medications, allergies, and any specific treatment requests from the patient.
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