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The form contains confidential health information that will be stored in the patient's electronic medical record.
Patients are asked if they were referred by another physician, which helps in understanding their healthcare journey.
Patients must list all medications, including over-the-counter drugs and vitamins, along with their dosages and refill needs.
The form includes a section to determine if patients have advanced directives like living wills or power of attorney.
It collects detailed medical history, including past illnesses, surgeries, and family health history.
The form assesses social history, including marital status, occupation, education level, and substance use.
Patients are prompted to provide information on their last physical exams and screenings for various health conditions.
