|
Diet Restrictions:
• • •
|
Diet Comment
|
|
HCV Screening
|
PSA Screening Date
|
|
Lipid Screening Date
|
Serum Glucose Date:
|
|
Colonoscopy Last Date
|
FOBT Last Date
|
|
Gynecological / Pap Last Date
|
Mammogram Last Date
|
|
Menstruation
• • •
|
Menstruation Comment
|
|
Gravida
|
Para
|
|
Childhood Immunization Hx
• • •
|
Childhood Immunizations Comment
|
|
Tobacco
• • •
|
Tobacco Comment
|
|
Caffeine
• • •
|
Caffeine Comment
|
|
Alcohol
• • •
|
Alcohol Comment
|
|
Marital Status
|
Marital Status Comment
|
|
Occupation
|
Exercise
|
|
FMHx Allergies
• • •
|
FMHx Alcoholism
• • •
|
|
FMHx Asthma
• • •
|
FMHx Anemia
• • •
|
|
FMHx Atopic Dz.
• • •
|
FMHx Thyroid Disease
• • •
|
|
FMHx Arthritis
• • •
|
FMHx Autoimmune Dz.
• • •
|
|
FMHx Bleeding Tendency
• • •
|
FMHx Breast Cancer:
• • •
|
|
FMHx High Cholesterol
• • •
|
FMHx Uterine Cancer
• • •
|
|
FMHx High Blood Pressure
• • •
|
FMHx Ovarian Cancer
• • •
|
|
FMHx Heart Disease
• • •
|
FMHx Colon Cancer
• • •
|
|
FMHx Stroke
• • •
|
FMHx Other Cancer
• • •
|
|
FMHx Obesity
• • •
|
FMHx Alzheimer's / Dementia
• • •
|
|
FMHx Diabetes
• • •
|
FMHx Parkinson's
• • •
|
|
FMHx Kidney Dz.
• • •
|
FMHx Psychological Dz.
• • •
|
|
FMHx Osteoporotic Fracture
• • •
|
FMHx Epilepsy
• • •
|
|
FMHx Other:
|
Past Surgical History:
|
|
Important Aspects of Medical History:
|
|
|
MEDICAL / FAMILY / SOCIAL HISTORY NOTES
|
|
