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 Warning 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 Warning If so, list the date of surgery. (YYYY-MM-DD) Warning Social History Smoker Yes No Warning Alcohol Consumption Yes No Warning Marital Status Single Married Windows Divorced Warning Family History Arthritis Autoimmune Disorder Asthma Cancer Diabetes Heart Disease High Blood Pressure High Cholesterol Kidney Disease Psychiatric Illness Stroke Other: Warning 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 Warning Current Immunizations? Yes No Warning Last Tetanus Warning Last Flu Vaccine Warning Last Pneumonia Vaccine Warning I certify that this form… Signature of Patient, Legal Guardian, or Authorized Person Warning Date (YYYY-MM-DD) Warning Person Warning Or Patient Name Warning Date (YYYY-MM-DD) Warning Relationship to Patient Warning Warning. SubmitSubmitting form Δ