|
Reviewed and unchanged
|
|
|
Past Medical History Freewrite
|
|
|
Past Surgical History
|
|
|
Family History
|
|
|
Father's MH
• • •
|
Comments
|
|
Mother's MH
• • •
|
Comments
|
|
Sibling(s)' MH
• • •
|
Comments
|
|
Grandparent's MH
• • •
|
Comments
|
|
Children(s)' MH
• • •
|
Comments
|
|
Family History Freewrite
|
|
|
Social History
|
|
|
Marital Status
• • •
|
Comments
|
|
Living Arrangements
• • •
|
Comments
|
|
Sexual Hx
|
Comments
|
|
Occupation
|
Comments
|
|
Caffeine
• • •
|
Caffeine Comment
|
|
Tobacco
• • •
|
Tobacco Comments
|
|
Alcohol
• • •
|
Alcohol comments
|
|
Drugs
• • •
|
Drugs comments
|
|
Diet
• • •
|
Diet Comments
|
|
Spiritual Beliefs
|
Religion Comments
|
|
Social Hx Freewrite
|
|
|
Health Care Maintenance
|
|
|
Advanced Directive on file
|
Advanced Directive Comments
|
|
Cervical Cancer Screening
|
Breast Cancer Screening
|
|
Pregnancies
|
Contraception/Protection
• • •
|
|
Colonoscopy
|
Prostate Cancer Screening
|
|
Influenza Vaccine
|
Pneumococcal Vaccine
|
|
Tetanus Booster
|
Shingles Vaccine:
|
|
HIV Screen
|
Hepatitis C Screen
|
|
DEXA
|
Dental Screening
|
|
Vision Screening
|
Dermatology
|
|
Diabetic Foot Exam
|
Last A1C
|
|
Home BG
|
Blood Work
|
