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How do I fill this out?
To fill out the questionnaire, begin by entering your personal information at the top. Next, provide details about your medical history and current medications. Finally, review your information and ensure completeness before submission.
How to fill out the UCLA Comprehensive New Patient Questionnaire?
1
Read each question carefully before answering.
2
Fill in all applicable fields related to your medical history.
3
List current medications, including dosages and frequency.
4
Provide information about your social history.
5
Review your answers for accuracy before submitting.
Who needs the UCLA Comprehensive New Patient Questionnaire?
1
New patients at UCLA Health looking to establish care.
2
Doctors needing patient medical history for diagnostic reasons.
3
Family members assisting patients in completing the form.
4
Healthcare providers reviewing comprehensive patient information.
5
Patients interested in documenting their medical conditions for future reference.
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How do I edit the UCLA Comprehensive New Patient Questionnaire online?
Editing this PDF on PrintFriendly is seamless and user-friendly. Simply open the PDF in the editor, make the necessary changes, and save your modifications. This feature helps you ensure all your information is accurate before final submission.
1
Open the PDF file in PrintFriendly.
2
Click on the edit option to make changes to your answers.
3
Update any outdated or incorrect information.
4
Save your edited document by downloading it.
5
Share your updated PDF as needed.
What are the instructions for submitting this form?
To submit this form, you can email it to the designated healthcare office at uclahealth@ucla.edu. Alternatively, you may send it via fax to (310) 825-1234. In-person submissions are also welcome at your local UCLA clinic.
What are the important dates for this form in 2024 and 2025?
Please ensure to submit your questionnaire at least one week prior to your appointment. If you have any upcoming appointments scheduled, you may want to fill this out as soon as possible. Future revisions of the form may be expected to be revised by 2025.
What is the purpose of this form?
This form is designed to gather comprehensive health information from new patients at UCLA Health. By collecting details regarding medical history, medications, and social factors, healthcare providers can tailor their services effectively. The completion of this questionnaire helps ensure that patients receive the best possible care.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes MRN and patient name.
- 2. Medical History: Details current and past health conditions, surgeries, and treatments.
- 3. Family Medical History: Records any hereditary conditions and their ages of onset.
- 4. Current Medications: Lists all prescribed medications and supplements.
- 5. Social History: Describes relationship status, sexual history, and lifestyle habits.
What happens if I fail to submit this form?
Failing to submit this form could delay your appointment and affect your care. Crucial health information may be missing, resulting in potential misdiagnosis or ineffective treatment.
- Incomplete Medical History: This may lead to complications in treatment and care.
- Appointment Delays: Not submitting could postpone your scheduled visit.
- Potential Misdiagnosis: Without full information, providers may not diagnose conditions accurately.
How do I know when to use this form?
- 1. New Patient Intake: To provide essential health information to the healthcare provider.
- 2. Understanding Patient History: Helps the provider become familiar with your medical background.
- 3. Medication Updates: Necessary for documenting any changes in medications since the last visit.
Frequently Asked Questions
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Can I edit the questionnaire after downloading?
Yes, you can edit the PDF anytime using PrintFriendly's editing tools.
What if I forget to fill out a section?
You can review and edit your answers before final submission.
Is the questionnaire confidential?
Yes, your information remains confidential and secure during the process.
Can I print the questionnaire after editing?
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What types of information does the questionnaire request?
It requests medical history, current medications, and social history.
How can I share the completed form?
You can share the form via email or social media directly from PrintFriendly.
Is there a time limit for submitting this form?
It's best to submit the form prior to your scheduled appointment.
What should I do if I have questions while filling it out?
Contact your healthcare provider for assistance with any questions.
Can I save the questionnaire to my device?
You can download the questionnaire to your device after editing.
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