Ohio State Wexner Medical Center Allergy/Immunology New Patient Questionnaire
This document is used by new patients at Ohio State Wexner Medical Center to provide their medical history, family history, and current health status. It's a comprehensive form that helps doctors understand the patient’s medical background. It also includes sections for medication allergies, social history, and environmental history.
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How do I fill this out?
To fill this form out, you need to provide detailed information about your current medications, past medical history, past surgical history, family history, social history, and more. Ensure you have all relevant information at hand before you begin. Each section needs to be carefully filled out for accurate medical assessment.
How to fill out the Ohio State Wexner Medical Center Allergy/Immunology New Patient Questionnaire?
1
Gather all your current medications and their dosages.
2
Detail your past medical and surgical history.
3
Provide information about your family’s medical history.
4
Answer questions about your social history and lifestyle.
5
Complete environmental and infection history sections.
Who needs the Ohio State Wexner Medical Center Allergy/Immunology New Patient Questionnaire?
1
New patients visiting Ohio State Wexner Medical Center need this form to provide their medical history.
2
Doctors at Ohio State Wexner Medical Center use this form to assess the medical background of new patients.
3
Patients with a history of allergies or immunological issues need this form for specialized medical assessment.
4
Parents or guardians filling out medical information for their children at the Ohio State Wexner Medical Center need this form.
5
Patients preparing for a consultation or follow-up visit at the allergy/immunology department need this form.
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What are the instructions for submitting this form?
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.
What are the important dates for this form in 2024 and 2025?
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).
What is the purpose of this form?
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.
Tell me about this form and its components and fields line-by-line.
- 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.
What happens if I fail to submit this form?
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.
How do I know when to use this form?
- 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.
Frequently Asked Questions
How do I fill out the Ohio State Wexner Medical Center Allergy/Immunology Questionnaire?
Provide detailed information about your medical history, current medications, family history, social history, and environmental history.
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You can share the completed form via email or a shareable link using PrintFriendly’s sharing feature.
What happens if I miss a section on the form?
Ensure that all required sections are completed for an accurate medical assessment. Incomplete forms may delay your consultation.
Can I save my progress and continue later?
Yes, you can save your progress and return to complete the form at a later time.
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