| Medical History |  | 
| Past Medical History• • • | Past Medical History Free write | 
| Past Surgical History• • • | Surgery Freewrite | 
| PCP |  | 
|  |  | 
| Family History |  | 
| Father's MH• • • | Father MHx | 
| Mother's MH• • • | Mother MHx | 
|  |  | 
| Social History |  | 
| Marital Status• • • | Alcohol | 
| Living Arrangements• • • | Smoking History• • • | 
| Occupation | Other substances | 
| Patient's diet | Comments | 

