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Medical History
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Medications
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Personal Medical History
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Comments
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Other medical problems not listed above:
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Past Surgical History
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Last Menstrual Cycle
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Colonoscopy
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Mammogram
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Dexa (Bone denisity)
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Pap
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Family History
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Father's MH
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Father:
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Mother's MH
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Mother:
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Siblings:
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Please list all other medical providers you see on a regular basis
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Social History
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Comments
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Marital Status
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Education Level
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Comments
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Are there any vision problems that affect your communication?
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Comments
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Are there any hearing problems that affect your communication?
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Smoking/ Tobacco Use
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Are there any limitations to understanding or following instructions (written or verbal)?
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Recreational Drug Use
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Current Living Situation
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Alcohol
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Patient's diet
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Are you sexually active?
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Are there any personal problems or concerns at home, work, or school you would like to discuss?
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How often do you get the social and emotional support you need?
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Are there any cultural or religious concerns you have related to our delivery of care?
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Comments (Please feel free to comment on any answeres marked "yes" above):
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Are there any financial issues that directly impact your ability to manage your health?
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Initial Risk Assessment
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Education
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Advance Directive
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Family History of
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