13 Health Information Forms

There are those times when you actually think that you are living with a healthy lifestyle. But the question is, do you really know what it means to be healthy? Indeed, being healthy makes you unstoppable to do all the things you wish to do, such as extracurricular and/or outdoor activity evaluations, or any escapades or adventures. When you are healthy, you are able to have more accomplishments. You also improve the relationship you have with your family, friends, and everyone around you. Thus, you are kept far from any heath complications, and you have your time completely controlled, managed, and balanced.

Your healthy condition would help you develop your skills, abilities, and intellectual capacity, in which you tend to be more responsive or active whenever the different circumstances are encountered. Being healthy would mean you being happy and worry-free. And by means of this, you do not just regain but also retain your focus and attention. Yet, what happens when you are not healthy is that you face some serious consequences. These outcome would make you prone to any diseases, health complications, or any disability reports. You lose control of yourself, that includes your emotions. And you fail to reach your goal to be healthy. Therefore, you have to know the risk.

In this article are few sample forms for health information that you may refer to. The essential parts are also indicated for you to be guided on what information should be included in the form. There are also few reasons or purposes of why health information forms are often utilized. Furthermore, few common ways on how you could be healthy are also provided for you. Take time to peruse over each of these free downloadable forms.

Blank Health Information Form

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Size: 10 KB

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Fillable Health Information Form

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Size: 108 KB

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Health Information Form for Student

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Size: 78 KB

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The Importance of Health Information Forms

These forms are often utilized for few justifiable reasons. Some of which are as follows:

  • When your health information is one of the required documents to be complied during the program or job applications
  • When a relative of a patient or an individual requests for a copy of the health information
  • When an individual wants to review the information regarding his or her past and current health conditions
  • When the record holder wishes to release his or her health records to some people

Health information forms are mainly used as a reference with regards to an individual’s health record. In addition, these could also be used to discover latent health complications. By means of discovering these, medical treatments are provided in order to avoid the worsening of these health issues or problems. Thus, a health assessment is conducted by an authorized healthcare personnel to ensure that an individual is capable of joining or applying in some activities or programs.

This assessment is also useful when one is seeking for a job, most especially those work that involves dangerous or risky tasks. Forms for health information allows you to fill out the necessary details regarding yourself, your family, your background and medical history. Some forms often include some questions for further assessment of your health, and to better understand the nature and the commencement or start of such hurdles.

These health information forms are often used to provide the information regarding the following:

  • The past and current diseases, injuries, ailments, or any condition that requires medication (either physical or mental health)
  • The required medications on a regular basis, what for, and why
  • The allergies from certain food, medicines, and other things that triggers your health complications

These forms are mandatory to be printed in two copies, in which one is obtained by the hospital or medical centers for patient reports or records, and the other by the patient or patient’s family.

General Health Information Form

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Size: 7 KB

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Exhaustive Health Information Form

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  • PDF

Size: 168 KB

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The Essential Parts of Health Information Form

These health information forms are completed upon the provision of all the necessary or required information. Thus, the list of the essential parts or details that are often needed to be provided are as follows:

  • The personal information of the information holder
    • The full name
    • The maiden name
    • The primary and alternate addresses
    • The contact information for home, personal, and business
    • The email address
    • The date of birth
    • The marital status
  • The identification verification includes the following details
    • The gender
    • The height and weight
    • The ethnicity or race
    • The eye and hair colors
    • The birthmarks or scars
    • The blood type classification
    • The languages spoken
    • The special conditions
  • The employment information
    • The occupation
    • The company name, contact number, and address
    • The primary and secondary health insurance carrier
    • The policy numbers
  • The emergency contact person information
    • The full name
    • The relationship to the patient or person
    • The complete address
    • The contact numbers for home, personal, and work
    • The email address
  • The healthcare service provider information or details
    • The service type
    • The name of the group or association
    • The complete address
    • The association contact number
    • The email address
    • The Web address/es or URL
  • The insurance verification providers’ information
    • The insurance type
    • The company name
    • The full or complete address
    • The contact person’s name
    • The identification number
    • The contact number
    • The email address
    • The Web address/es
    • The primary insured person’s name
  • The medical history or records
    • The infectious diseases
    • The immunizations or vaccines taken
    • The allergies or drug sensitivities
      • The date onset
      • The age when perceived
      • The reactions made by the allergies
      • The date last occurred
      • The treatment/s implemented
      • The remarks regarding the allergies or sensitivities
    • The legal documents or medical directives
  • The family medical member history or background
  • The lifestyle and health log with regards to non-infectious major illnesses
    • The date when diagnosed
    • The name of the attending physician at the moment
    • The nature of the health problem/s
    • The age at onset
    • The condition status
    • The remarks regarding the treatments undertook by the physician
  • The current medication information
    • The name of medication
    • The dosage
    • The frequency
    • The date started
    • The stop date
    • The quantity
    • The person or physician who prescribed the medication
    • The prescription date
    • The allergic restrictions
    • The comments with the medication
  • The doctor visits’ log
    • The date of visit
    • The doctor’s name
    • The reason for such visit
    • The diagnosis
  • The hospitalizations’ details
    • The date for admission
    • The doctor’s name or attending physician
    • The hospital or medical center
    • The reasons for admission
    • The diagnosis
    • The complications
    • The discharge date
  • The surgeries’ details
    • The date of surgery
    • The attending surgeon’s name
    • The hospital or medical center
    • The procedures performed
    • The descriptions regarding the surgeries
    • The result or outcome after surgery
    • The surgeon or doctor’s comments and recommendations
  • The laboratory tests, imaging, and medical devices used
    • The test or device type
    • The date of when certain tests are performed
    • The name of the requesting doctor
    • The hospital lab of where specific tests are performed
    • The reason/s why such lab tests are done
    • The result from different lab tests
    • The attachments of the results
  • The physical report or occupational therapy
    • The therapy type
    • The start and stop date
    • The frequency of how often therapy is conducted
    • The name of the therapist
  • The vision and dental examination check-ups
    • The date of visit
    • The attending ophthalmologist’s or dentist’s name
    • The complications found
    • The resolutions made

These information are found on those samples for exhaustive health information forms in which all details that could be used as a reference are provided for health record review. When all these information are indicated in the form, the health condition/s is or are described briefly. Thus, the warning signs, triggers, and the circumstances are identified, as well as the recommended responses. For that reason, documents or records are needed to be attached in the health information form for further references.

Another thing that is essentially added in the form is the physician’s medical statement with regards to the findings or diagnosis. The reason for this is because there are such terms in which only the medical or healthcare personnel can understand. Therefore, using health information forms to indicate all the results would help the medical record holder and his or her family to understand these results. With all the necessary information included in the form, it is mandatory for the physician’s signature to be affixed in the form. This is in order to confirm that the following medical assessments and tests, as indicated in the form, are performed.

Information that are provided or written in the form should be true, correct, accurate, and precise. Otherwise, the application form for some program applied for, in which health information is required, will be dismissed or disapproved. With this kind of information, the form is secured and obtained by the authorized personnel due to the fact that these details written in the form are confidential. The person responsible for the leakage of some health records of an individual would be held liable to any consequences that may result from this kind of act. Unless, the owner or holder of such leaked information has given his or her consent to release the information. Refer to the sample forms provided for you below.

Consent to Disclose Health Information

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Size: 577 KB

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Release of Health Information Form

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Size: 77 KB

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Authorization for Release of Health Information

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Size: 87 KB

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As you have observed in the form provided for you above, there are essential information that are used to specify who are the people who could have access to these confidential information. These are as follows:

  • The patient’s name, contact number, and address
  • The name, address, and contact number of the person to whom health information is released
  • The facility or provider’s name and contact number of the person from whom health information is released
  • The reason or purpose why such disclosure agreement is necessary
  • The date/s of service requested
  • The list of information to be released
  • The specific date of when the authorization remains effective
  • The patient or participant consent or authorization (name, signature, and date signed)
  • The representative’s name, signature, date, and the relationship to the patient (if in case that the information is authorized in behalf of the patient)

When all these information or details are provided by the patient or the representative in behalf of the patient, the hospital, or medical health centers releases any liabilities with regards to these. Yet, everyone should still take heed of the consequences when these confidential information are diffused to the public.

Few Common Ways to Be Healthy

For you to ensure that you are healthy, here are the common ways (that you probably know already) on how to be healthy.

  • Eat healthy foods by means of having a balanced diet, and by drinking plenty of water.
  • Have a healthy lifestyle by making your surroundings clean at all times, and by following your daily routine.
  • Exercise more often to ensure that you are physically fit.
  • Make sure to visit your doctor once in a while, or have a regular check-up.
  • Make sure that you do not forget the medical intake, vitamins, and minerals that were prescribed to you by your doctor.

Those are the most common ways that you often hear when people give you advice on how to be healthy. Here are more:

  • Know and set your short-term and long-term goals. By doing this, you tend to be stimulated in reaching one goal after the other.
  • Know and accept your flaws. By means of this, you are developing yourself and your maturity level. You tend to beat the old you so you can become the new you.
  • Never stop learning. After all, life is a learning process and we never stop learning as each day passes by.
  • Challenge yourself. Have the guts to go beyond your limits, as you aim high in achieving more accomplishments.
  • Keep in touch with your loved ones. Make sure that you keep your line on, since family and loved ones could help you get motivated in your daily life.
  • Socialize with other people. It is never good to always hide inside your shell and shut other people out. You need to socialize in order to boost your confidence.

When you have taken note of all these ways to a healthy lifestyle, you may perform a self-assessment in order to see how much you have changed. Ask yourself whether you have improved or worsened. Whatever the result is, you have to keep going. And do not just stop there, not until you have proven yourself to be self-driven.

Participants’ Health Information Form

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Size: 129 KB

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Standard Health Information Form

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Size: 547 KB

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Application Health Information Form

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Size: 104 KB

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Patient Request for Health Information

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Size: 64 KB

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Student Health Information Form

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Size: 630 KB

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Summing these all up, being healthy does not just mean by being physically fit. As a matter of fact, it means you are contented with what you currently have. Though, it does not necessarily mean that you do not desire for more. It is just that you are happy for what it is you have in the present and you look forward for what is/are to come in the near future. By means of this, being healthy does not just pertain to you being physically fit but also emotionally, intellectually, spiritually, and socially.

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