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DR4085NY OMB NO. 09300270 Expiration Date 08/31/2015 Project # Individual/Family Crisis Counseling Services Encounter Log Provider Name ADELAIDE OF SUFFOLK COUNTY, Inc. Date of Service (mm/dd/YYY)
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How to fill out individualfamilyencounterform 101512 reformatted 1
How to fill out individualfamilyencounterform 101512 reformatted 1:
01
Start by entering the date of the encounter in the designated section.
02
Provide your full name, date of birth, and contact information in the personal details section.
03
Next, indicate the reason for the encounter and any symptoms or complaints you have.
04
In the medical history section, provide details about any pre-existing conditions, surgeries, or allergies you have.
05
If applicable, list any medications you are currently taking, including dosage and frequency.
06
Describe any recent medical procedures or tests you have undergone.
07
In the social history section, provide information about your lifestyle, including smoking habits and alcohol consumption.
08
Document your family history, noting any hereditary diseases or conditions.
09
Answer any additional questions or provide any other relevant information requested on the form.
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Finally, sign and date the form to confirm that the provided information is accurate and complete.
Who needs individualfamilyencounterform 101512 reformatted 1:
01
Patients visiting a healthcare facility or clinic for an individual/family medical encounter.
02
Individuals seeking medical care who are required to provide a detailed medical history.
03
Healthcare providers or administrators who use this form to gather essential patient information for treatment and record-keeping purposes.
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