DA Form 4465. Patient Intake/Screening Record (PIR)

Form DA 4465 is a record form used in medical settings to gather essential information during the intake and screening process of patients. This form serves as a comprehensive record of the patient's medical history, current condition, and initial assessment.

The form consists of sections where healthcare providers can collect relevant information about the patient, including personal details, medical history, current symptoms or complaints, medications, allergies, and any other pertinent information necessary for the initial assessment and screening process.

Important fields in this form include the patient's personal information, such as name, date of birth, and contact details, as well as detailed sections to document the patient's medical history, current symptoms, and initial assessment findings. Accurate and complete information should be provided to ensure proper diagnosis and treatment planning.

Application Example: Healthcare providers medical settings can use this form during the intake and screening process of patients. The form should be completed with accurate and comprehensive information about the patient's medical history, current condition, and initial assessment findings. This form is useful for establishing a baseline record of the patient's health status and guiding subsequent medical interventions.

Related Forms: There may not be direct alternatives to Form DA 5, as it specifically addresses patient intake and screening records. However, other forms related to medical history, consent, or specific medical assessments may exist, depending on the specific healthcare setting or purpose.