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FORM #1.2 Headfirst HISTORY & PHYSICAL FORM Page 1 of 3 Name (Print): Date: Last First MI List your MAIN COMPLAINTS: Describe your condition (onset, cause, etc.) List the date & type of diagnostic
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How to fill out history amp physical form
How to Fill Out History & Physical Form:
01
Start by carefully reading the instructions provided on the form. Make sure you understand the purpose and required information for each section.
02
Begin by filling out the personal information section, including your full name, date of birth, address, and contact details. It is essential to provide accurate and up-to-date information.
03
Proceed to the medical history section. Fill in details about any past medical conditions, surgeries, or hospitalizations you have experienced. Include any known allergies or adverse reactions to medications.
04
Answer the questions regarding family medical history. Provide information about any genetic conditions, prevalent diseases, or hereditary disorders that run in your family.
05
Move on to the lifestyle and social history section. This will typically cover topics such as tobacco or alcohol use, exercise habits, and any occupational or environmental exposures that may be relevant to your health.
06
Provide a comprehensive list of all current medications and supplements you are taking. Include the name, dosage, and frequency of each medication.
07
Complete the physical examination section by accurately documenting your height, weight, blood pressure, and any other relevant measurements. If you have undergone recent diagnostic tests or imaging, mention them here.
08
Finally, sign and date the form, affirming the accuracy and completeness of the information provided. If required, you may also need a healthcare provider's signature or stamp.
Who Needs History & Physical Form:
01
Individuals seeking medical care or undergoing certain procedures are often required to complete a history and physical form. This can include patients visiting a new primary care physician, specialists, or entering a hospital or surgical facility.
02
Students participating in school sports or enrolling in certain educational programs, such as nursing or allied health fields, may also be asked to fill out a history and physical form.
03
Individuals applying for certain jobs that involve physical fitness or require healthcare clearances may need to submit a history and physical form as part of the application process.
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