Register your Medical Information - Form

Take an active role in managing your health and register your medical information with us.

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(( Whilst registration posts are visible to you, realistically you wouldn't have access to them. Therefore, don't roleplay that you obtained somebody's medical information from a registration form they posted on our forums, as that would be a breach of metagaming rules. ))
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Roan Roybal
Hospital Leadership
Hospital Leadership
Posts: 275
Joined: Sat Jul 17, 2021 9:55 pm

Register your Medical Information - Form

Post by Roan Roybal »

Code: Select all

[divbox=white]

[center][img]https://i.imgur.com/Hxjt4M2.png[/img][/center]

[/divbox]
[br][/br]
[divbox=lightgrey][color=#800000][b]SECTION 1: PATIENT INFORMATION[/b][/color][/divbox]
[divbox=white][table][tr][td][b]1.1[/b] Title[/td][td]
Write here

[tr][td][b]1.2[/b] Name[/td][td]
Write here

[tr][td][b]1.3[/b] Date of Birth[/td][td]
Write here

[tr][td][b]1.4[/b] Gender[/td][td]
Write here

[tr][td][b]1.5[/b] Race/Ethnicity[/td][td]
Write here

[tr][td][b]1.6[/b] Height[/td][td]
Write here

[tr][td][b]1.7[/b] Weight[/td][td]
Write here

[tr][td][b]1.8[/b] Phone Number[/td][td]
Write here

[tr][td][b]1.9[/b] Email Address[/td][td]
Write here (( Include main GTAW's profile name & Discord ID ))

[tr][td][b]1.10[/b] Occupation[/td][td]
Write here

[tr][td][b]1.11[/b] Primary Language[/td][td]
Write here


[tr][td][b]1.12[/b] Home Address[/td][td]
Write here

[/table][/divbox]
[br][/br]
[divbox=lightgrey][b][color=#800000][b]SECTION 2: PAST MEDICAL HISTORY[/b][/b][/divbox]
[divbox=white][table][tr][td][b]2.1[/b] Blood Type[/td][td]
Write here

[tr][td][b]2.2[/b] Chronic Medical Conditions[/td][td]
Write here (e.g., Hypertension, Diabetes, Asthma)

[tr][td][b]2.3[/b] Hospitalizations[/td][td]
Write here (Reasons and dates)

[tr][td][b]2.4[/b] Major Illnesses[/td][td]
Write here (e.g., heart attack, stroke)

[tr][td][b]2.5[/b] Previous Surgeries[/td][td]
Write here (Include dates and nature of injuries)

[tr][td][b]2.6[/b] Traumas & Injuries[/td][td]
Write here (Include dates and nature of injuries)

[tr][td][b]2.7[/b] Transfusions or Organ Transplants[/td][td]
Write here (Specify details and dates)

[tr][td][b]2.8[/b] Women's Health History:[/td][td]
Write here (For female patients - include details about pregnancies, menstrual history, etc.)

[/table][/divbox]
[br][/br]
[divbox=lightgrey][b][color=#800000][b]SECTION 3: MEDICATION HISTORY[/b][/divbox]
[divbox=white][table][tr][td][b]3.1[/b] Current Medications[/td][td]
Write here (List with dosage and frequency)[/td]

[tr][td][b]3.2[/b] Previous Medications[/td][td]
Write here (Include reasons for discontinuation)

[tr][td][b]3.3[/b] Over-the-Counter Medications[/td][td]
Write here (Include vitamins and supplements)

[tr][td][b]3.4[/b] Herbal Supplements[/td][td]
Write here (Include any herbal remedies)

[tr][td][b]3.5[/b] Medication Allergies:[/td][td]
Write here (Specify reactions)

[/table][/divbox]
[br][/br]
[divbox=lightgrey][b][color=#800000][b]SECTION 4: FAMILY MEDICAL HISTORY[/b][/divbox]
[divbox=white][table][tr][td][b]4.1[/b] Immediate Family Members[/td][td]
Write here (Include any significant medical conditions or hereditary diseases)

[tr][td][b]4.2[/b] Genetic Conditions[/td][td]
Write here (if known)

[tr][td][b]4.3[/b] Family Social History[/td][td]
Write here (Include information about family dynamics, support systems)

[/table][/divbox]
[br][/br]
[divbox=lightgrey][b][color=#800000][b]SECTION 5: SOCIAL HISTORY[/b][/divbox]
[divbox=white][table][tr][td][b]5.1[/b] Living Situation[/td][td]
Write here (Alone, with family, with partner, assisted living)

[tr][td][b]5.2[/b] Marital Status[/td][td]
Write here (Single, married, divorced, widowed)

[tr][td][b]5.3[/b] Number of Children[/td][td]
Write here (if applicable)

[tr][td][b]5.4[/b] Sexual Orientation[/td][td]
Write here (Your self-identified sexual orientation)

[tr][td][b]5.5[/b] Cultural or Religious Considerations[/td][td]
Write here (Any relevant practices or beliefs)

[tr][td][b]5.6[/b] Financial Status[/td][td]
Write here (Include information about financial challenges and your overall financial situation)

[/table][/divbox]
[br][/br]
[divbox=lightgrey][b][color=#800000][b]SECTION 6: MENTAL HEALTH HISTORY[/b][/divbox]
[divbox=white][table][tr][td][b]6.1[/b] Diagnosed (Current or Previous) Mental Health Conditions[/td][td]
Write here (List any diagnosed mental health conditions, such as depression, anxiety, bipolar disorder, schizophrenia, etc.)

[tr][td][b]6.2[/b] Therapies or Counseling[/td][td]
Write here (Specify any previous or ongoing therapies, counseling, or mental health interventions. Include types (e.g., cognitive-behavioral therapy, psychoanalysis) and durations)

[tr][td][b]6.3[/b] Hospitalizations for Mental Health[/td][td]
Write here (Note any past hospitalizations related to mental health. Provide reasons for hospitalizations and the dates of these occurrences)

[tr][td][b]6.4[/b] Triggers or Stressors[/td][td]
Write here (Identify specific triggers or stressors that may contribute to mental health challenges. This could include life events, relationships, work-related issues, etc.)

[tr][td][b]6.5[/b] Support Systems[/td][td]
Write here (Highlight any existing support systems, such as friends, family, or support groups, that play a role in the patient's mental health journey)

[tr][td][b]6.6[/b] Coping Mechanisms[/td][td]
Write here (Describe any coping mechanisms or strategies you employ to manage your mental health. This could include hobbies, activities, or mindfulness practices)

[tr][td][b]6.7[/b] Suicidal or Self-Harm History[/td][td]
Write here (If applicable, include any history of suicidal thoughts, self-harm, or suicide attempts. Specify when these incidents occurred and any relevant details)

[/table][/divbox]
[br][/br]
[divbox=lightgrey][b][color=#800000][b]SECTION 7: ADDITIONAL INFORMATION[/b][/divbox]
[divbox=white][table][tr][td][b]7.1[/b] Healthcare Preferences[/td][td]
Write here (Specify any specific preferences or considerations related to healthcare. This could include preferences for certain healthcare providers, treatment methods, or any cultural or religious considerations that may impact healthcare decisions)

[tr][td][b]7.2[/b] Dietary Preferences or Restrictions[/td][td]
Write here (Include any specific dietary preferences or restrictions that are relevant to your overall health. This may include dietary preferences (vegetarian, vegan), or restrictions due to health conditions)

[tr][td][b]7.3[/b] Exercise Routine[/td][td]
Write here (Describe your current exercise routine, if applicable. Include the type, frequency, and duration of physical activities you engage in regularly)

[tr][td][b]7.4[/b] Sleep Patterns[/td][td]
Write here (Share details about your sleep patterns, including the average number of hours of sleep you get each night, any difficulties with sleep, or relevant sleep disorders)

[tr][td][b]7.5[/b] Smoking or Substance Use[/td][td]
Write here (Indicate if you smoke or use any substances. Include details about frequency and duration of use)

[tr][td][b]7.6[/b] Sexual Health[/td][td]
Write here (Share relevant information about your sexual health, including any concerns, practices, or history of sexually transmitted infections)

[tr][td][b]7.7[/b] Stress Management Strategies[/td][td]
Write here (Discuss any strategies you currently use to manage stress. This could include activities like meditation, mindfulness, or other stress-relief practices)

[tr][td][b]7.8[/b] Occupational or Environmental Exposures:[/td][td]
Write here (Specify any occupational or environmental exposures that may impact your health. This could include exposure to certain chemicals, substances, or environmental conditions)

[tr][td][b]7.9[/b] Travel History[/td][td]
Write here (Provide information about recent or significant travel history, especially if you have traveled to areas with specific health risks or exposures)

[tr][td][b]7.10[/b] Other Relevant Information[/td][td]
Write here (Include any other information you believe is relevant to your overall health and well-being. This could encompass unique aspects of your lifestyle, personal preferences, or important details that you want your healthcare providers to be aware of)

[/table][/divbox]
[br][/br]
[divbox=lightgrey][b][color=#800000][b]SECTION 8: EMERGENCY CONTACT INFORMATION[/b][/divbox]
[divbox=white][table][tr][td][b]8.1[/b] Name[/td][td]
Write here (Emergency Contact's Full Name)

[tr][td][b]8.2[/b] Relationship[/td][td]
Write here (Emergency Contact's Relationship to You)

[tr][td][b]8.3[/b] Phone Number[/td][td]
Write here (Emergency Contact's Contact Number)

[tr][td][b]8.4[/b] Email Address[/td][td]
Write here (Emergency Contact's Email, if available) (( Include main GTAW's profile name & Discord ID ))

[/table][/divbox]
[br][/br]
[divbox=lightgrey][color=#800000][b]SECTION 9: DISCLAIMER[/b][/color][/divbox]
[divbox=white][br][/br]
[list=none]
I, [Your Full Legal Name], hereby declare that the information provided in this medical history form is true, accurate, and complete to the best of my knowledge. I understand that this information will be stored securely within the systems of Pillbox Hill Medical Center and may be accessed by authorized healthcare professionals involved in my care.

I, [Your Full Legal Name], upon submitting this form, consent to the sharing of my medical information among healthcare professionals within Pillbox Hill Medical Center for the purpose of providing comprehensive and coordinated healthcare services. I acknowledge that this information may be used for diagnosis, treatment, and other healthcare-related activities in accordance with applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA).

I, [Your Full Legal Name], understand that the security and privacy of my medical information are of utmost importance to Pillbox Hill Medical Center, and I trust that all necessary measures will be taken to safeguard my information in compliance with legal and ethical standards.

I, [Your Full Legal Name], retain the right to revoke this consent at any time by notifying Pillbox Hill Medical Center in writing. However, I also understand that revoking consent may limit the ability of healthcare professionals to provide me with optimal and coordinated care.
[br][/br]
[/list][/divbox]
[br][/br]
[divbox=lightgrey][color=#800000][b]SECTION 10: PAYMENT[/b][/color][/divbox]
[divbox=white][table][tr][td][b]10.1[/b] Please attach an unedited copy of your payment, unless you are excempt [size=70](see question 14 in the FAQ thread on how to pay)[/size][/td][td]
[url=insert the image link here]Proof of Payment[/url]
[/table][/divbox]



Image

SECTION 1: PATIENT INFORMATION
1.1 Title Write here
1.2 Name Write here
1.3 Date of Birth Write here
1.4 Gender Write here
1.5 Race/Ethnicity Write here
1.6 Height Write here
1.7 Weight Write here
1.8 Phone Number Write here
1.9 Email Address Write here (( Include main GTAW's profile name & Discord ID ))
1.10 Occupation Write here
1.11 Primary Language Write here
1.12 Home Address Write here

SECTION 2: PAST MEDICAL HISTORY
2.1 Blood Type Write here
2.2 Chronic Medical Conditions Write here (e.g., Hypertension, Diabetes, Asthma)
2.3 Hospitalizations Write here (Reasons and dates)
2.4 Major Illnesses Write here (e.g., heart attack, stroke)
2.5 Previous Surgeries Write here (Include dates and nature of injuries)
2.6 Traumas & Injuries Write here (Include dates and nature of injuries)
2.7 Transfusions or Organ Transplants Write here (Specify details and dates)
2.8 Women's Health History: Write here (For female patients - include details about pregnancies, menstrual history, etc.)

SECTION 3: MEDICATION HISTORY
3.1 Current Medications Write here (List with dosage and frequency)
3.2 Previous Medications Write here (Include reasons for discontinuation)
3.3 Over-the-Counter Medications Write here (Include vitamins and supplements)
3.4 Herbal Supplements Write here (Include any herbal remedies)
3.5 Medication Allergies: Write here (Specify reactions)

SECTION 4: FAMILY MEDICAL HISTORY
4.1 Immediate Family Members Write here (Include any significant medical conditions or hereditary diseases)
4.2 Genetic Conditions Write here (if known)
4.3 Family Social History Write here (Include information about family dynamics, support systems)

SECTION 5: SOCIAL HISTORY
5.1 Living Situation Write here (Alone, with family, with partner, assisted living)
5.2 Marital Status Write here (Single, married, divorced, widowed)
5.3 Number of Children Write here (if applicable)
5.4 Sexual Orientation Write here (Your self-identified sexual orientation)
5.5 Cultural or Religious Considerations Write here (Any relevant practices or beliefs)
5.6 Financial Status Write here (Include information about financial challenges and your overall financial situation)

SECTION 6: MENTAL HEALTH HISTORY
6.1 Diagnosed (Current or Previous) Mental Health Conditions Write here (List any diagnosed mental health conditions, such as depression, anxiety, bipolar disorder, schizophrenia, etc.)
6.2 Therapies or Counseling Write here (Specify any previous or ongoing therapies, counseling, or mental health interventions. Include types (e.g., cognitive-behavioral therapy, psychoanalysis) and durations)
6.3 Hospitalizations for Mental Health Write here (Note any past hospitalizations related to mental health. Provide reasons for hospitalizations and the dates of these occurrences)
6.4 Triggers or Stressors Write here (Identify specific triggers or stressors that may contribute to mental health challenges. This could include life events, relationships, work-related issues, etc.)
6.5 Support Systems Write here (Highlight any existing support systems, such as friends, family, or support groups, that play a role in the patient's mental health journey)
6.6 Coping Mechanisms Write here (Describe any coping mechanisms or strategies you employ to manage your mental health. This could include hobbies, activities, or mindfulness practices)
6.7 Suicidal or Self-Harm History Write here (If applicable, include any history of suicidal thoughts, self-harm, or suicide attempts. Specify when these incidents occurred and any relevant details)

SECTION 7: ADDITIONAL INFORMATION
7.1 Healthcare Preferences Write here (Specify any specific preferences or considerations related to healthcare. This could include preferences for certain healthcare providers, treatment methods, or any cultural or religious considerations that may impact healthcare decisions)
7.2 Dietary Preferences or Restrictions Write here (Include any specific dietary preferences or restrictions that are relevant to your overall health. This may include dietary preferences (vegetarian, vegan), or restrictions due to health conditions)
7.3 Exercise Routine Write here (Describe your current exercise routine, if applicable. Include the type, frequency, and duration of physical activities you engage in regularly)
7.4 Sleep Patterns Write here (Share details about your sleep patterns, including the average number of hours of sleep you get each night, any difficulties with sleep, or relevant sleep disorders)
7.5 Smoking or Substance Use Write here (Indicate if you smoke or use any substances. Include details about frequency and duration of use)
7.6 Sexual Health Write here (Share relevant information about your sexual health, including any concerns, practices, or history of sexually transmitted infections)
7.7 Stress Management Strategies Write here (Discuss any strategies you currently use to manage stress. This could include activities like meditation, mindfulness, or other stress-relief practices)
7.8 Occupational or Environmental Exposures: Write here (Specify any occupational or environmental exposures that may impact your health. This could include exposure to certain chemicals, substances, or environmental conditions)
7.9 Travel History Write here (Provide information about recent or significant travel history, especially if you have traveled to areas with specific health risks or exposures)
7.10 Other Relevant Information Write here (Include any other information you believe is relevant to your overall health and well-being. This could encompass unique aspects of your lifestyle, personal preferences, or important details that you want your healthcare providers to be aware of)

SECTION 8: EMERGENCY CONTACT INFORMATION
8.1 Name Write here (Emergency Contact's Full Name)
8.2 Relationship Write here (Emergency Contact's Relationship to You)
8.3 Phone Number Write here (Emergency Contact's Contact Number)
8.4 Email Address Write here (Emergency Contact's Email, if available) (( Include main GTAW's profile name & Discord ID ))

SECTION 9: DISCLAIMER

  • I, [Your Full Legal Name], hereby declare that the information provided in this medical history form is true, accurate, and complete to the best of my knowledge. I understand that this information will be stored securely within the systems of Pillbox Hill Medical Center and may be accessed by authorized healthcare professionals involved in my care.

    I, [Your Full Legal Name], upon submitting this form, consent to the sharing of my medical information among healthcare professionals within Pillbox Hill Medical Center for the purpose of providing comprehensive and coordinated healthcare services. I acknowledge that this information may be used for diagnosis, treatment, and other healthcare-related activities in accordance with applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA).

    I, [Your Full Legal Name], understand that the security and privacy of my medical information are of utmost importance to Pillbox Hill Medical Center, and I trust that all necessary measures will be taken to safeguard my information in compliance with legal and ethical standards.

    I, [Your Full Legal Name], retain the right to revoke this consent at any time by notifying Pillbox Hill Medical Center in writing. However, I also understand that revoking consent may limit the ability of healthcare professionals to provide me with optimal and coordinated care.


SECTION 10: PAYMENT
10.1 Please attach an unedited copy of your payment, unless you are excempt (see question 14 in the FAQ thread on how to pay) Proof of Payment
Image
Roan Roybal, MS, AGACNP, FAANP
Chief Nursing Officer Email: [email protected]
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