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How to fill out health forms
Most clinics and doctor's offices give you forms to fill out. These forms ask for things like your name, birth date, and social security or immigrant visa number. They may also ask for health insurance information (if you have it).
If you have trouble reading the form, you can get help. You could bring along a friend to help or translate. Or, you can ask the nurses or clinic staff to help you. You can also ask for a translator. Don't feel bad about asking. Part of their job is to help with things you don't understand.
Here are some things you will need for your visit:
- Date of birth — The day of the month and the year that you were born.
- Social security number or immigrant visa number — Offices and clinics may need this to charge for the visit. It also helps identify your records.
- Health insurance card — The card your insurance company sent you.
- Emergency contact number — The phone number(s) of the person(s) to call in an emergency. This could be a relative, friend, neighbor, or boss.
- Medicines — Bring a list of all the medicines you use. This includes prescriptions, over-the-counter drugs, and herbs and supplements. Or, put all of them in a bag and bring them with you. The doctor or nurse will write down the names for you.
- Health problems — The form might ask about your health problems. This means things like diabetes, high cholesterol, or other conditions. The form might also ask about your family members' problems. If you don't know, just say so.
- Lifestyle — The form might ask you about your lifestyle. Some questions might be about things like sex, alcohol, or drug use. This might seem too personal to share. But, be honest with the doctor. Your doctor needs to know everything about you to give you the best care. Don't worry — the information you share with your doctor is private.
Explore other publications and websites
Information to Help You Fill Out the “1-800-MEDICARE Authorization to Disclose Personal Health Information” Form — This resource gives you step-by-step instructions on how to fill out a disclosure of personal health information form from Medicare.
Connect with other organizations
Agency for Healthcare Research and Quality
America’s Health Insurance Plans
American Association of Retired Persons (AARP)
Centers for Medicare and Medicaid Services, HHS
Content last updated May 18, 2010.
Resources last updated May 18, 2010.
A federal government website managed by the Office on Women's Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services.
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