Five Things to Know When Filling Out Medical Forms

The amount and complexity of paperwork patients encounter during a doctor’s appointment can seem daunting. Baylor University Robbins College of Health and Human Sciences Associate Professor Beth Lanning, PhD, MCHES remembered how, after a series of medical visits, her own mother didn’t want to fill out forms anymore.

“Age and health really affect your ability to comprehend … and it just becomes overwhelming,” Lanning said. “I think we find that a lot of our patients, young and old, depending on their literacy and education level, feel exactly that way—probably overwhelmed by the amount of paperwork and what to fill out.”

Professor Lanning was a member of a team of Baylor faculty who researched the effectiveness of several health literacy measurement tools. The study, led by fellow Baylor professor Kelly Ylitalo, PhD, outlines two tests: the Newest Vital Sign (NVS) nutrition label test (PDF, 1.5 MB) and a single-item confidence questionnaire. 

The questionnaire asks, “Are you confident filling out medical forms and describing your health?” Answers can include responses such as “extremely confident,” “somewhat confident,” and “not at all confident.” 

Patients that claim to be “confident” filling out medical forms are identified as having little difficulty understanding medical information. But not everyone feels that secure when they walk into the doctor’s office. 

Understanding your physical and psychological condition is a key starting point to creating sustainable outcomes and a positive relationship with healthcare providers. For young adults entering appointments on their own for the first time, individuals who have a lot of questions, and caregivers helping others navigate the health system, it can be difficult to know where to begin.

Below are five things that everyone should know about their own health to have confident interactions with healthcare providers. Included are common questions and tips for how to improve health literacy in these areas.

1. Personal Information 

Personal information is the most basic knowledge needed to accurately complete medical forms. These identifiers answer questions such as “Who are you and how can we contact you?” Establishing a robust personal profile with a provider ensures you can always be reached and your preferences are respected and followed.

Things you might need to know:

  • Full and legal name
  • Home address
  • Date of birth
  • Emergency contact information
  • Phone number and email address
  • Preferred method of contact
  • Changes in marital or job status 

Remember:

  • Arrive 15–30 minutes early to give yourself time to fill out forms.
  • Bring a personal identification card so you have an easy reference point.
  • Use a piece of paper to cover the page and reveal questions one at a time, making it easier to read and less overwhelming. 

2. Health Insurance

Health insurance is payment coverage for medical, dental, behavioral, and prescription services through a private company or the government, like Medicare or Medicaid. Households can usually acquire coverage through an individual’s job or insurance plan. Each policyholder should have their own insurance card with a personal ID number. 

Things you might need to know:

  • The information presented on your insurance card
  • If you’ve met your deductible for the year
  • What the copay will be
  • If a provider is in or out-of-network

Common questions:

What is a sliding scale? A sliding scale is a method of charging patients without insurance coverage a reduced rate for their services. The amount charged is based on a variable, usually income.

Do I have to pay at the time of the appointment? That depends on the office and provider. Ask when you make your initial appointment and see what options they have for deferring payment or paying in installments, if necessary. 

Remember to:

  • Bring your insurance card to every appointment. If you have questions, the office staff can call your insurer to resolve any issues.
  • Select your provider with the insurance company before your appointment, if required. They may need to send you a new insurance card.
  • Check coverage levels and network status in advance either by calling the insurance company or logging on to their website.

3. Reason for the Appointment

Your symptoms answer what could likely be the first question your healthcare provider asks you: What brings you here today?

Things you might need to know:

  • When you made the appointment
  • What kind of discomfort you’re experiencing and where
  • How long you’ve been experiencing symptoms
  • How often you experience the symptoms
  • Changes in patterns, like rapid weight gain or loss of sleep
  • Objectives for the appointment

Common questions:

I made the appointment because I need a physical—there’s nothing wrong with me. What do I say? Physicals are annual checkups usually covered entirely by insurance, for preventive care. If that’s the reason for your appointment, it’s perfectly fine to say you are experiencing no symptoms.

I don’t know how to word what I’m feeling. Share that with the provider. They can offer visual tools to help you express your concerns or discomfort.

Remember to:

  • Use travel time to think about your goals for this trip.
  • Record how you’re feeling at the time of making the appointment. What prompted you to make the call? Continue to write down the frequency or intensity of symptoms leading up to the appointment and bring the document with you.
  • Ask open-ended questions if you’re helping someone else through the appointment. Instead of “Your stomach hurts, right?” try “How do you feel after you eat?” 

4. Medical History

Your medical history describes your past interactions with the healthcare system and your outcomes. Most of it should exist in your patient documents, which many providers will ask that you share when you enter their practice. If you’re transferring offices or switching providers, contact your former medical office and sign a release form that will allow them to forward your past medical history to your new provider.

Things you might need to know:

  • Allergies
  • Vaccination history
  • Medication and prescriptions used
  • Past surgeries and hospitalizations
  • Drug and alcohol use and frequency
  • Sexual history
  • Last fall and frequency of falls

Common questions:

What if I can’t remember everything? You don’t have to remember everything. Most of these questions can be answered using patient documents collected throughout your interactions with providers. Focus on remembering the most recent instances that aren’t captured there. 

What if I get something wrong? Your provider will not base a new treatment or medication recommendation based solely on your memory alone. Share what you can to provide helpful context, but don’t feel like it’s your responsibility to keep track of everything.

Remember to:

  • If you’re switching providers, call in advance of your new appointment and ask how to request medical records. Contact the old provider, too, and sign a release form granting them permission to fulfill the request.
  • Work through your own medical history using categories that make sense to you. Do you need to recall what procedures you’ve had? Think chronologically, recount medical treatments from head to toe, or reflect on the different categories of operations to organize your thoughts.

5. Family Medical History

Family medical history is higher level and focuses on answering the question “How could your family’s health be affecting your experiences?”

Things you might need to know:

  • Family members’ chronic conditions or diseases like:
    • High cholesterol
    • High blood pressure
    • Cancer
    • Heart disease
    • Diabetes
    • Dementia
  • When were they diagnosed?
  • Are they medicated for it?
  • Mental health conditions like alcoholism or depression
  • Pregnancy complications

Common questions:

How far into my family history do I need to go? You don’t need a full family tree, but start with your biological parents and whatever information you can gather from them. After that, move on to their biological parents. 

What if I can’t find the answer? If you don’t have access to information for your biological parents, don’t guess at what it could be. Share that you can’t provide those answers and let your provider guide you to next steps. Some providers will refer you to a genetic counselor who can test what hereditary conditions run in your family.

Remember to:

  • Document what you find by jotting down notes and bringing them to the appointment.
  • Ask family members about their medical conditions. If they can’t remember, ask them to contact their own provider to look them up.
  • When it comes to hereditary conditions, your family’s health directly affects your own. Even if it feels uncomfortable, it’s worth starting a conversation.

Citation for this content: The MPH online program from Baylor University's Robbins College of Health and Human Sciences.