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COLORADO DEPARTMENT OF TRANSPORTATION SUPPLEMENTAL MEDICAL HISTORY REPORT INSTRUCTIONS Employee Physician Complete this form and return to supervisor for processing. This form may be retained with

How to fill out supplemental medical history report

How to fill out a supplemental medical history report:

1. Start by carefully reading the instructions provided with the report. Familiarize yourself with the required information and any specific guidelines given.
2. Begin filling in the personal information section, including your name, date of birth, contact information, and any other details requested.
3. Follow the prompts to provide details about your medical history. Be thorough and accurate in documenting any past diagnoses, surgeries, allergies, medications, or treatments you have received.
4. Include information about any ongoing medical conditions or chronic illnesses you may have. Specify the duration and severity of these conditions, as well as any current treatments or medications being used.
5. If applicable, provide details about any previous hospitalizations or emergency room visits. Include the dates, reasons, and outcomes of these visits.
6. Use the space provided to list any current or recent medications you are taking. Include the names, dosages, and frequency of administration for each medication.
7. If you have any known drug allergies or adverse reactions to specific medications, indicate them clearly in the designated section.
8. Supply information on any family history of medical conditions, such as heart disease, diabetes, or cancer. Include the names of affected family members and their relationship to you.
9. If relevant, provide information about any lifestyle factors that may impact your health, such as smoking, alcohol consumption, or physical activity levels.
10. Finally, review your completed form for accuracy and completeness before submitting it. Make sure all sections have been addressed and that your handwriting is legible.

Who needs a supplemental medical history report?

A supplemental medical history report may be required by various healthcare institutions or professionals, including doctors, hospitals, clinics, and specialists. It can be beneficial for both new and existing patients to provide a comprehensive overview of their medical background, ensuring accurate diagnosis, treatment planning, and continuity of care. Additionally, individuals participating in medical research studies or clinical trials may also need to submit a supplemental medical history report as part of their enrollment process.

For pdfFiller’s FAQs

What is supplemental medical history report?

Supplemental medical history report is a document that provides additional medical information beyond the initial patient history for a more comprehensive health assessment.

Who is required to file supplemental medical history report?

Healthcare providers, medical personnel, or patients may be required to file a supplemental medical history report depending on the medical situation or specific health conditions.

How to fill out supplemental medical history report?

To fill out a supplemental medical history report, the individual should provide detailed information about any relevant medical events, treatments, or changes in health status since their last medical assessment.

What is the purpose of supplemental medical history report?

The purpose of a supplemental medical history report is to ensure that healthcare providers have up-to-date information about a patient's health condition, medical treatments, and any new developments that may impact their care.

What information must be reported on supplemental medical history report?

The supplemental medical history report should include details about any new medical diagnoses, changes in medications, hospitalizations, surgeries, or major health events that have occurred since the last medical assessment.

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