Name Date Nick Name DOB Marital Status Current Medications and DosingDo you have any medicalconditionsYesNoIf so please explainSurgeries Year Year Year Year Year Year List any hospitalizationsAl ID: 884942
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Name _______________________________ Date _______________ Nick Name ___________________________ DOB _______________ Occupation __________________________ Marital S t atus ________ Current Medications and Dosing: _________________________________________ _____________________ ______________________________________________________________ ______________________________________________________________ Do you have any medical conditions ? Yes No If so, please explain___________________________________________ ___ ______________________________________________________________ ______________________________________________________________ Surgeries: ________________ Year ____ ________________ Year ____ ________________ Year ____ ________________ Year ____ ___ _____________ Year ____ ________________ Year ____ List any hospitalizations: _______________ _________________ ____ _ ___________________________________ ________ ________________________________________________________________ Allergies to Medications and R eactions, Please List: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ When was you r last Pap?________________________ NA ______ When was your last Mammogram? _________________/ Where ____________ NA ___ When was
2 your last Dexa Scan? ________________/
your last Dexa Scan? ________________/ Where ______________ NA____ When was your last Colonoscopy _____________ / Where _______________ NA _____ Who lives in your household with you? ________________________________________ Do you smoke/chew Yes No #________/day Any blood related mal es under 55 yrs. of age had a heart attack? Yes No Any blood related femal es under 65 yrs. of age had a heart attack? Yes No Do you use recreational drugs? Yes No if yes , which ones __________________ Have you ever smoked / use chew Yes No Year Quit ___________ Coffee/Caffeine Yes No # cups p er day ________ Alcohol Yes No #________/day, week, month Exercise Yes No if so, what? _______________________ #____________ minutes/day #___________/week Your exposure to the sun is: Rare Occasional or Frequent Has any blood rel ation in your family had the following? If yes, please list relation and age Cancer: Colon __________________________________ Breast ________________________________ _ Prostate ________________________________ Ovarian ____________________________ _____ High Blood Pressure __________________________________ Heart Attack __________________________________ Stroke __________________________________ Diabetes __________________________________