New Patient Intake Medical History Form: Fill & Download for Free

New Patient Evaluation and Management are ALWAYS much more comprehensive, and therefore yes, costly. The first time a physician sees a patient, they know nothing about them. They have a plethora of intake forms, personal medical history, family medical history, presenting complaints, visual assessment, etc that they must pour through in order to get this first ‘snapshot’ of who is sitting in front of them. What is their lifestyle and how does it affect their health? What is their family and psychological history? What surgeries, major illnesses or hospitalizations have they had to undergo?It’s much simpler once all that info has been assembled into a chart and the Dr gets to know you. It takes a great deal more time, on the average, to consult with a New Patient.They can do this because it is not only legal but REQUIRED by law. There are codes specific to New Patients that go on an insurance claim. If an insurance company gets a claim for a patient, from a provider they’ve never seen before, and the claim form has an ‘Established patient’ service code on it, guess what happens? Ya. The insurance kicks it back and says, ‘Wait a minute. We’ve never seen a claim for this patient from this provider. It should be a New Patient visit’. Denied. To code an established patient service, which costs less, is called ‘downcoding’. It’s illegal.So I hope that this answers your question from both a logical and legal standpoint. From here on, your bill won’t say ‘new’.

Suggested starting point: As an AEMT, how do I ask a transgender person for their biological gender without being offensive?Also suggested: New article identifies issues for transgender treatment in emergency departmentsWhen you’re pulling health history from a trans patient assumptions can make your life difficult and many healthcare intake processes aren’t designed to catch trans people in a normal intake.Last time I did an intake (two weeks ago), the nurse doing the intake never noticed that I’m trans and the only clue the surgeon had was that my medications included a really high dose of spironolactone (okay, it’s not high for trans people but if you’re used to spiro in other contexts, it’s really high.)If you don’t know that the person you’re talking to is trans, and if they don’t volunteer that information (given the rates at which trans people are assaulted and harassed by medical providers there are reasons that many of us won’t tell medical providers that we’re trans) you may not have any indication that they are trans.If you know that they’re trans, making sure that you are using their name and preferred pronouns (if you don’t know, ask) and then let them know that you need to get some medical history information from them, some of which may pertain to the gender they were assigned at birth and their transition history.The important thing for health providers to understand is that trans people have a really hard time trusting medical care providers and you need to understand why this is sensitive… it’s not just about respecting our identity, it goes further than that.Nearly 1 in 5 transgender people have been denied medical care for being transgenderOver 25% of trans people have been harassed by care providers2% of trans people have been victims of violence in doctor’s offices, 1% were victims of violence in emergency roomsMore than 25% of trans people have delayed seeking treatment for fear of harassment in medical settings, 1 in 3 have delayed preventive care for the same reason.[1]If you want actual and effective methods of gathering information, it needs to happen at an organizational and process level. Patients need to be given an opportunity to self report transgender status and they need to be made aware that it is safe for them to do so. Medical intake forms need to be designed in a way that allows you to gather health information from transgender patients which may pertain to the gender they were assigned at birth rather than the gender they identify as.Going back to my recent intake: The patient medical history process was digital and one of the things I appreciated is that I was able to mark N/A on every piece of medical history that pertained to having a uterus (when was your last period, are you undergoing menopause, etc.) That’s good. What’s not good is that there was nowhere that the process captured information about things like date of last prostate exam. For trans men who may have marked “Male” on the form, it is unlikely they would have been presented an opportunity to provide potentially relevant information that pertains to having a uterus (all of those things I marked N/A to.)I wish I could give you something simple and easy. Some phrase you could use or questions you can ask. The truth, sadly, is messier than that and real effective change is going to have to come from institutions. If providers join the push for tools that allow them to effectively identify and treat trans patients, that kind of pressure from within the system can be a significant part of achieving that change.As always, I’m available in the comments for further questions and to expand on any of the above.Footnotes[1] http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf

When a physician takes a medical history, we look at all aspects of who you are which might in some way influence your health. This may include questions about place of birth, education, work, hobbies, living situation, economic circumstances, and family and intimate relationships. None of these questions are for gossip purposes, rather they alert us to circumstances which may affect either the cause or course of a medical condition. Family dynamics and stressors (emotional, logistical, economic) sometimes come into play when medical illness is involved; the ability of someone to deal with an illness may be very different depending on whether they a) have no children, b) have children living at home who they are responsible for, c) have children with complex medical needs, d) have adult children living nearby who can help in an emergency, or e) have children they are estranged from (to name just a few possibilities). This makes no difference whether you’re a man or a woman. Regardless, you are under no requirement to answer the question. Just know that if a patient’s response to the question “Do you have any children?” was something like “I’d rather not say.”, I’d probably spend a whole lot more time wondering about it than any other answer they could possibly give.