Annual Physical Exam Instructions and Health History Assessment
This file provides important instructions for patients undergoing an Annual Physical Exam. It includes details about covered and non-covered services as well as a thorough health history assessment for the patient. Patients are advised to read this document carefully before their appointment.
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How do I fill this out?
To fill out this form, start by providing your basic personal details. Next, complete the health history assessment by responding to all the questions about your current and past health conditions. Make sure to sign and date the document to validate your information.
How to fill out the Annual Physical Exam Instructions and Health History Assessment?
1
Start by filling in your basic personal details including name and address.
2
Complete the health history assessment sections by answering all relevant questions.
3
List your current medications, dosage, and frequency taken.
4
Provide details about your past surgeries and family health history.
5
Sign and date the document to confirm the accuracy of your information.
Who needs the Annual Physical Exam Instructions and Health History Assessment?
1
Patients undergoing an Annual Physical Exam to understand what is covered during the visit.
2
Healthcare providers to gather a comprehensive health history of their patients.
3
Insurance companies to determine the coverage of preventive services for their clients.
4
Caregivers and family members to keep track of the patient's health history and needs.
5
Medical record departments to maintain detailed patient health information.
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Click on the text fields to enter or update information.
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Use the editing tools to add, remove, or modify text as needed.
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Review all sections for accuracy and completeness.
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Save and download the edited file for your records.
What are the instructions for submitting this form?
Submit the completed form to your healthcare provider at the address: Capital Family Physicians, P.A., 2417 Atrium Drive, Suite 201, Raleigh, North Carolina 27607. You may also fax it to 919-232-0030. Ensure that all sections are completed and the form is signed and dated before submission. For any questions, contact (919) 232-0020.
What is the purpose of this form?
The purpose of this form is to ensure that patients understand what is covered during their Annual Physical Exam. It helps to inform patients about covered and non-covered services and provides an opportunity to gather comprehensive health history information. Properly completed forms enable healthcare providers to offer better care and ensure proper billing with insurance companies.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Chart#: A unique identifier for the patient's medical records.
- 2. Patient Details: Includes patient's name, address, and contact information.
- 3. Medical and Family History: Details about the patient’s past and current health conditions, including family health history.
- 4. Current Medications: List of medications currently being taken by the patient, including dosage and frequency.
- 5. Surgeries/Hospitalizations: Details of any past surgeries or hospitalizations with dates.
- 6. Preventive Screenings: Dates of last conducted preventive screenings such as mammogram, chest X-ray, etc.
- 7. Lifestyle Information: Information about daily habits such as tobacco and alcohol use, living situation, and social support.
- 8. Special Diet/Exercise: Details about special diets, exercise routines and any difficulties tolerating activities.
- 9. Signature: Patient’s signature to validate the provided information.
What happens if I fail to submit this form?
Failing to submit this form can result in delays in receiving your Annual Physical Exam. It may also lead to incomplete documentation which can affect the quality of care provided. Furthermore, insurance claims might not be processed correctly.
- Delayed Exam: Without the form, your Annual Physical Exam may be postponed.
- Incomplete Health Records: Missing information could lead to incomplete health history documentation.
- Insurance Issues: Incomplete forms can result in issues with insurance claim processing.
How do I know when to use this form?
- 1. Annual Physical Exam: To document patient’s preventive health services and history.
- 2. Insurance Documentation: To provide detailed information for insurance claims processing.
- 3. Health History Update: To keep the healthcare provider updated on the patient’s health status.
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