Identity
pg 1 of 7
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
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Past Medical History
pg 2 of 7
Anemia
Anxiety
Arthritis
Asthma
Atrial fibrillation
Benign prostatic hypertrophy
Blood clots
COPD
Coronary artery disease
Crohn's disease
Depression
Diabetes
GERD
Heart attack
Hepatitis C
High blood pressure
High cholesterol
Insomnia
Irritable bowel syndrome
Kidney disease
Liver disease
Migraines
Osteoporosis
Seasonal allergies
Seizures
Sleep apnea
Stroke
Thyroid disease
Ulcers
Ulcerative colitis
Valley fever
Cancer
Breast cancer
Colon cancer
Lung cancer
Ovarian cancer
Prostate cancer
Other
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Past Surgical History
pg 3 of 7
Orthopedic Surgeries
Back surgery
Carpal tunnel release
Hip replacement
Hip surgery
Knee replacement
Knee surgery
Shoulder surgery
Other Surgeries
Appendectomy
Cataract extraction
Colectomy
Colostomy
Coronary stents
Gall Bladder surgery
Gastric bypass
Heart bypass
Heart valve
Hernia repair
LASIK
Pacemaker
Prostatectomy
Thyroid surgery
Tonsilectomy
Vasectomy
Other
For Women Only
Breast augmentation
Cesarean section
Ovaries removed
Hysterectomy due to Fibroids
Hysterectomy due to Endometriosis
Hysterectomy due to heavy bleeding
Hysterectomy due to cancer
Mastectomy
Tubal ligation
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Family History
pg 4 of 7
Please indicate if your mother, father, or sibling(s) have or had any of the following diseases.
Adopted, or Family History is Unknow
No Relevant Family History
Mother
Father
Sister(s)
Brother(s)
Alzheimer's disease
Stroke
Diabetes
Heart attack before 60
Heart attack after 60
High blood pressure
High cholesterol
Colon cancer
Breast cancer
Ovarian cancer
Alive and Well
Alive
Deceased
Are any family members deceased?
Mother
Father
Sister(s)
Brother(s)
Mother's cause of death?
Father's cause of death?
Sister's cause of death?
Brother's cause of death?
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Social History
pg 5 of 7
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Race
White
African-American
Asian
Native American
Other
Language
English
Spanish
Chinese
French
Other
Marital Status
Married
Single
Divorced
Widowed
Life partner
Diet
Poor
Average
Healthy
Vegetarian
Vegan
Consume caffeine daily?
Yes
No
Most common caffeine source?
Other caffeine source?
Average servings of caffeine per day?
Exercise frequency
2-3 times/week
3-4 times/week
Daily
Occationally
Rarely/Never
Occupation?
Do you have children?
Yes
No
Number of boys?
Number of girls?
Highest education completed?
None
Elementary school
High school
GED
College
Graduate school
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Tobacco Use History
pg 6 of 7
Have you ever used tobacco?
Yes
No
Describe your tobacco use.
Current cigarette smoker
Former cigarette smoker
Current cigar/pipe smoker
Former cigar/pipe smoker
Current chewing tobacco/snuff user
Former chewing tobacco/snuff user
Current vape/smokeless tobacco user
Former vape/smokeless tobacco user
Current smoker details:
Use Daily?
Packs per day
Number of years
Age started
Cigarettes
Former smoker details:
Former packs per day
Number of years
Age started
Age stopped
Cigarettes
Current cigar/pipe smoker details:
Use Daily?
Number per day
Number of years
Age started
Cigar
Pipe
Former cigar/pipe smoker details:
Number per day
Number of years
Age started
Age stopped
Cigar
Pipe
Current chewing tobacco/snuff user details:
Use Daily?
Ounces per day
Number of years
Age started
Chewing tobacco
Snuff
Former chewing tobacco/snuff user details:
Ounces per day
Number of years
Age started
Age stopped
Chewing tobacco
Snuff
Current vape/smokeless tobacco details:
Use Daily?
Units per day
Number of years
Age started
Vape/smokeless tobacco
Former vape/smokeless tobacco details:
Units per day
Number of years
Age started
Age stopped
Vape/smokeless tobacco
Do you have substancial second-hand smoke exposure?
Yes
No
Alcohol Use History
Do you drink alcohol?
Yes
No
Frequency?
Daily
Weekly
Monthly
Occasionally
Rarely
Drinks per period?
1 drink
2 drinks
3 drinks
4 or more drinks
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Review of Systems
pg 7 of 7
Check Yes/No for EACH item if you are experiencing that symptom TODAY
*
Yes
No
Fever
Vision changes
Hearing loss
Cough
Shortness of breath
Chest pain
Irregular heart beat
Constipation
Diarrhea
Vomiting
Abdominal pain
Excessive thirst
Pain during urination
Blood in urine
Headaches
Cold intolerance
Heat intolerance
Rash
Joint or bone pain
Bruising
Bleeding
Environmental allergies
Submit
Should be Empty: