Submit the completed form to the Ohio State Wexner Medical Center via the preferred method. You can email the form to wexnermedical@osumc.edu, fax it to (614) 293-3121, or submit it online through the patient portal at osuhealthplan.com. Additionally, you can mail the form to Ohio State Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210. Ensure all information is complete and accurate before submission for timely processing.

Important dates for this form in 2024 and 2025 include: January 1st (New Year's Day), March 17th (St. Patrick's Day), July 4th (Independence Day), November 28th (Thanksgiving), and December 25th (Christmas).

The purpose of this form is to collect comprehensive medical information from new patients at the Ohio State Wexner Medical Center. It includes sections for personal information, medical history, family history, and social history to provide doctors with a detailed understanding of the patient's background. Accurate completion of this form is essential for effective medical assessment and treatment planning. Having this information helps doctors make informed decisions about the patient's health and treatment options. It covers a wide range of medical history, including past medical conditions, surgeries, medication allergies, and family history. Social history and environmental factors are also considered to get a holistic view of the patient's health. The form ultimately ensures that the medical team has all the necessary information to provide the best possible care for the patient. It streamlines the process of patient intake and helps avoid any medical oversights during consultations.

• 1. Patient Name: The full name of the patient.
• 2. Patient Address: The home address of the patient.
• 3. Primary Care Doctor: The name of the patient's primary care physician.
• 4. Current Medications: Information about current medications the patient is taking, including dosage and frequency.
• 5. Date of Birth: The patient's date of birth.
• 6. Phone: The patient's contact phone number.
• 7. Past Medical History: Details about the patient's past medical conditions and treatments.
• 8. Past Surgical History: Information about any surgeries the patient has undergone, including approximate dates.
• 9. Family History: Medical history of the patient's family, including parents, siblings, and children.
• 10. Medication Allergies: Details about any allergies to medications, including the reaction and when it occurred.
• 11. Social History: Information about the patient's lifestyle, including tobacco and alcohol use.
• 12. Vaccination History: Details about the patient's vaccination history and any adverse reactions to vaccines.
• 13. Infection History: Information about any infections the patient has had.
• 14. Symptoms: Details about the symptoms bringing the patient to the medical center.
• 15. Review of Systems: A review of various bodily systems to identify any additional symptoms or concerns.
• 16. Environmental History: Information about the patient's home environment and any potential allergens.

Failing to submit this form may result in delays in your medical consultation and treatment. Accurate and complete information is crucial for proper medical assessment and care planning.

• Delayed Treatment: Incomplete medical information can delay the start of treatment as doctors will not have all the necessary background.
• Inaccurate Assessment: Without complete information, doctors may not be able to make accurate diagnoses or provide the best treatment recommendations.

• 1. New Patient Registration: To provide your medical history when registering as a new patient.
• 2. Medical Assessment: For doctors to assess your medical background during consultations.
• 3. Allergy and Immunology Consultations: To provide detailed information for specialized assessments.
• 4. Updating Medical Records: To update your medical records with current health information.
• 5. Pre-Appointment Preparation: To ensure all necessary information is available before your appointment.