NWSPM Patient Questionnaire

Patient Questionnaire

Part 1: Demographics
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Marital Status*

Single, not in a relationshipSingle with significant otherMarriedDivorcedWidowed
Children - Total number*

012345
Dependents (children, other family members) living in the home*

012345
Patient Questionnaire

Part 2: Habits
Do you exercise (for at least 20-30 minutes)?*
Do you use tobacco?*
Are you interested in help to stop using tobacco?*

YesNo
Do you drink alcohol?*
Please check all that you are CURRENTLY using (within the last month):*

MarijuanaAmphetamine, methamphetamineCocaineHeroinEcstacyPrescription medications NOT prescribed to meNONE
Please check all that you have used within the last YEAR:*

MarijuanaAmphetamine, methamphetamineCocaineHeroinEcstacyPrescription medications NOT prescribed to meNONE
Do you drink caffeinated beverages?*
Which caffeinated beverages do you drink regularly?*

CoffeeTeaSoda / PopEnergy DrinksNONE
Patient Questionnaire

Part 3: Educational and Work History
Are you currently in school?*
When was the last time you were in school (year)?*
What is the highest level of schooling you have finished?*
Are you currently employed?*
When was the last time you worked if not currently working (year)?*
What has been your primary occupation? What sort of work have you done?*
Have you ever served in the military?*
Which branch of the military did you serve under?
What years did you serve (year to year)?
Did you ever experience combat while serving?
Were you injured during your time of service?
Do you receive disability benefits from your time of service?
Patient Questionnaire

Part 4: Surgical History
Please list all surgeries you have had (surgery type, year):
Should be Empty: