Patient health history form

What is a patient health history form?

A patient health history form is a document that is used to record the medical history of a patient during their physical or medical examination. The medical history of a patient gives an overview of past surgeries, hospitalizations, injuries, allergies, and other conditions. The healthcare provider then uses this information to provide the best possible treatment and help improve the quality of life of the patient. 

Why is a patient health history form necessary?

A patient health history form is a crucial tool to assess the health history of the patient to understand the overall health condition of the patient. It helps the healthcare make an informed decision with respect to the planned course of treatment. The absence of such information can leave gaps in the patient’s treatment plan, or worse, can worsen their condition. For instance, if the healthcare provider isn’t aware of any allergies that the patient has had in the past, and if he recommends medication that can trigger allergies, then the patient’s condition might deteriorate instead of improving. 

What details are included in a patient health history form?

A patient health history form must include the following details: 

• Personal details of the patient 
• Purpose of visit 
• Medical history (Surgeries, hospitalizations, injuries, allergies)
• Family history (Conditions that run in the family like diabetes, blood pressure issues, heart problems, etc)
• Medications taken by the patient
• Lifestyle habits (Alcohol consumption, smoking, diet, exercise routine, etc)
• Symptoms 
• Health goals

Who fills out a patient health history form? 

A patient health history form is typically filled out by a patient to give a clear and accurate account of their medical history. In case the patient is a minor, their parent or legal guardian will have to fill out the form. All the information mentioned in the form must be accurate so that the healthcare provider can assess all the concerns, make a diagnosis, and provide the appropriate treatment. 

As a facility owner is a patient health history form mandatory?

Collecting and using patient health information comes with a lot of responsibility as it needs to be done with absolute care and in compliance with HIPAA regulations. As per HIPAA, covered entities including healthcare facilities are required to obtain written consent from the patient before disclosing their information for payment or treatment purposes. Failure to do so can lead to serious repercussions in the form of civil and even criminal penalties.