Have you ever had any of the following? Anxiety/Depression Alcoholism Arthritis Asthma/COPD/Breathing Problems Allergies Blood Clots/Bleeding Disorders Cancer CAD/CHF/Heart Problems Diabetes Drug Addiction Dizzy/Fainting Spells Ear Infections Eye Problems High Blood Pressure High Cholesterol Headaches Kidney Disease/Stones Liver Disease/Hepatitis Mental Illness Sleep Disorder Seizures Stomach Disease/Reflux Spine Problems Stroke Sexually Transmitted Disease Thyroid Disease Trauma/Injury Urinary Tract Infections Other Past Surgical History – Have you had any of the follow surgeries? Appendectomy Cardiac Bypass/Pacemaker/CABG Cholecystectomy C-Section Carpel Tunnel Hysterectomy Tonsillectomy/Adenectomy Tubal Ligation Thyroid Surgery Vasectomy Other If so, list the date of surgery. (YYYY-MM-DD) Social History Smoker Yes No Alcohol Consumption Yes No Marital Status Single Married Windows Divorced Family History Arthritis Autoimmune Disorder Asthma Cancer Diabetes Heart Disease High Blood Pressure High Cholesterol Kidney Disease Psychiatric Illness Stroke Other: Screening Studies List when you last had the following tests done. EKG/Cardiac Work Up Cholesterol/Diabetes Screening Breast Exam/Mammogram PAP Smear/Vaginal Exam Rectal/Flex Sig/Colonoscopy PSA/Prostate Exam Current Immunizations? Yes No Last Tetanus Last Flu Vaccine Last Pneumonia Vaccine I certify that this form… Signature of Patient, Legal Guardian, or Authorized Person Date (YYYY-MM-DD) Person Or Patient Name Date (YYYY-MM-DD) Relationship to Patient Submit Δ