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Patient and Family bMedical History Formbpages - Billings Clinic 2025

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The document is a medical intake form for patients, collecting information about their injuries, medical history, current medications, and family medical history. It includes sections for detailing the nature of the injury, previous treatments, pain assessment, and lifestyle factors such as tobacco and alcohol use. The form also gathers information on diagnostic studies and allows for additional comments regarding the patient's condition.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information, including your name and medical record number at the top of the form.
Fill in details about your primary care and referring doctors, as well as the nature of your injury if applicable. Indicate whether it was a motor vehicle accident or work-related injury.
Describe your illness or injury in detail, including any previous consultations with other doctors and any x-rays or studies conducted.
Complete the medical history section by checking all relevant conditions that apply to you, such as high blood pressure or diabetes.
List any allergies and current medications you are taking, ensuring to provide accurate dosages.
Provide information on previous surgeries and family medical history by checking applicable conditions.
Finally, sign the form at the bottom and ensure all sections are completed before submitting.

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