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In general, a medical history includes an inquiry into the patients medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
The information collected on this form is used to assist DoD physicians in making determinations as to acceptability of applicants for military service and verifies disqualifying medical condition(s) noted on the prescreening from (DD 2807-2)/.
In general, a medical history includes an inquiry into the patients medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
Documentation typically reports why the patient was seen, what assessment or treatment was provided, clinical findings (e.g., diagnoses), and what (if any) treatment was recommended and provided in a way that justifies the assigned diagnosis and procedure codes (see Coding for Reimbursement).
Adult patients may complete their own histories, and minor children must have a parent or guardian complete their history.
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List all your past medical problems and surgeries. Include all your current medications and dosage and how you really take those medications most patients arent taking their medicines as prescribed and it helps doctors to know this information.
The summary must contain information for each injury, illness, or episode and any information included in the record relative to: chief complaint(s), findings from consultations and referrals, diagnosis (where determined), treatment plan and regimen including medications prescribed, progress of the treatment, prognosis
Log symptoms and side effects. Note any changes in nutrition, activity and stress levels. Also keep a log of how you or your loved one responded to any medications and treatments. Be specific with the name of the medication, the dose and what happened.

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