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State of Colorado Medical History Statement for Long Term Disability Standard Insurance Company For Residents of: Colorado Medical Underwriting, 900 SW Fifth Avenue Portland OR 97204 DIRECTIONS FOR

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How to fill out medical history statement for

How to fill out a medical history statement:

01

Start by providing personal information: Begin by filling in your full name, date of birth, and contact information. This includes your address, phone number, and email. Make sure to provide accurate and up-to-date information.

02

Specify any previous medical conditions: Indicate any past or present medical conditions you have had or are currently experiencing. This can include chronic illnesses, allergies, surgeries, or hospitalizations. Be as specific as possible and include relevant dates if necessary.

03

Include medication details: Mention any prescription medications, over-the-counter drugs, or supplements you are currently taking. Provide the name of the medication, dosage, frequency, and the condition it is being used to treat.

04

Mention any known allergies: List any allergies you have, including medication, food, or environmental allergies. Specify the type of allergic reaction you experience and any necessary precautions or treatment.

05

Provide family medical history: Include any significant medical conditions that run in your family, such as heart disease, cancer, diabetes, or mental health disorders. Include the relationship to the family member and their age at diagnosis if possible.

06

Note any lifestyle habits or risk factors: Mention any habits or behaviors that may contribute to your overall health and well-being. This can include smoking, alcohol or drug use, exercise routine, or dietary preferences.

07

Remember to sign and date: Once you have completed the medical history statement, make sure to sign and date it. This signifies that the information provided is accurate to the best of your knowledge.

Who needs a medical history statement?

01

Patients visiting a new healthcare provider: When seeing a new healthcare provider for the first time, they will typically request a medical history statement to understand your health background better. This helps them provide appropriate care and make informed decisions regarding treatment.

02

Individuals undergoing medical procedures: Before undergoing certain medical procedures or surgeries, healthcare providers need to assess your medical history to minimize risks and complications. This information is vital in determining the overall safety and suitability of the procedure for you.

03

Health insurance applications or claims: When applying for health insurance or filing a claim, insurers often require a medical history statement to assess your level of risk and determine premiums. This helps them understand any pre-existing conditions you may have and calculate the potential cost of your coverage.

In summary, filling out a medical history statement involves providing personal information, listing previous medical conditions, medications, and allergies, sharing family medical history, and noting lifestyle habits. This document is commonly needed by new healthcare providers, individuals undergoing procedures, and for health insurance purposes.

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What is medical history statement for?

Medical history statement is used to provide healthcare providers with information about a patient's past and current medical conditions, treatments, and family medical history.

Who is required to file medical history statement for?

Anyone seeking medical treatment or undergoing a medical procedure may be required to fill out a medical history statement.

How to fill out medical history statement for?

To fill out a medical history statement, individuals should provide accurate and detailed information about their medical conditions, treatments, medications, and family medical history in the form provided by their healthcare provider.

What is the purpose of medical history statement for?

The purpose of a medical history statement is to help healthcare providers make informed decisions about a patient's care, treatment options, and potential risks based on their medical history.

What information must be reported on medical history statement for?

Information that must be reported on a medical history statement includes past and current medical conditions, treatments, surgeries, hospitalizations, medications, allergies, family medical history, and lifestyle factors that may impact health.

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