Defect YN Kidney Disease YIN Cancer YIN Learning Disability YN COPD YN Do you smoke now DYES D NO Packsday 025 05 1 15 2 3 Years 05 1 No Do you consume caffeine DYES D Marital Status DSi ID: 894177
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1 Phone: Cell Phone: Work Phone Language:
Phone: Cell Phone: Work Phone Language: Need Interpreter: Ofes Q\Jo Marital Status: Religion: Race: Ethnicity: o-:iispanic/Latino 0-Jot Hispanic/Latina O,Jnknown [J\Jo Response Primary Care Provider/Family Doctor: Email Address: Is legal counsel involved Defect Y/N _ Kidney Disease YIN _ Cancer YIN _ Learning Disability Y/N _ COPD Y/N Do you smoke now DYES D NO Packs/day _0.25 _ 0.5 -1 -1.5 -2 _
2 3 Years -0.5 -1 _No Do you consume caff
3 Years -0.5 -1 _No Do you consume caffeine? DYES D Marital Status: DSingle D Married D Widow D Divorced Spouse Name: Number of Children Yrs of Education Occupation: HEALTH MAINTENANCE Colonoscopy: D YES D Dexa (Bone) at 1st Birth Age/Year Menopause Last Pap Smear NO Year: __ _ Influenza Immunization: NO Year: __ _ Pneumonia Vaccine: NO Year: __ _ NO Year: Pregnancies Total Full-Term Pre-Term
3 (37 wks) Miscarriages Elective Abortions
(37 wks) Miscarriages Elective Abortions D Separated DYESD DYESE3 DYES NO Year: pigmentation Cardiovascular: Chest Pains Dizziness Racing Heart Shortness of Breath Swollen Feet or Ankles Leg Cramps Irregular Heartbeat Poor Circulation Respiratory: Wheezing Frequent Cough Cough up Phlegm Cough up Blood Excessive Sweating Sit up to Sleep Trouble Breathing Digestive: Frequent Indigestion Heartburn F
4 requent Belching Bloated Stomach Loss of
requent Belching Bloated Stomach Loss of Appetite Nausea or Vomiting Spit up Blood Constipation Diarrhea Black/Grey/Bloody Stools Rectal Pain Rectal Bleeding Change in Stools Urinary: Frequent Urination Burning or Pain Trouble Starting Bedwetting Dribbling/Incontinence Brown/Black/Bloody Urine Head Date: _____ PPPPPPP _ Ag bs gyb yb PPPPPP _ Toxhb ySSSPPSS_ 7 IFPPPPPPPP_ hoc t gpo PPP d PPP