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Medical History
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Medical History
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Medical History
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Medical History (Other)
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Medical History [Comments]
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Medications
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Current Medications
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Current Medications
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Current Medications
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Surgical/Trauma History
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Surgical/Trauma History
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Surgical/Trauma History
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Surgical/Trauma History (Other)
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Surgical/Trauma History [Comments]
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Social History
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Social History
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Smoking
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Do You Currently Smoke?
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Frequency [cigarettes/day | packs/day]
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Did you smoke in the past?
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When did you quit?
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Describe how you smoke.
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Duration [years]
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Alcohol
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Do You drink alcohol?
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Frequency [drinks/week]
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Duration [days | months | years]
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Has patient had withdrawals/seizures due to alcohol use in the past?
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Has patient experienced blackout(s) due to alcohol use in the past?
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Have you ever felt you should cut down on your drinking?
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Have people annoyed you by criticizing your drinking?
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Have you ever felt bad or guilty about your drinking?
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Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
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Familial
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Married/Companion?
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Number of Children
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Number of Dependents
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Illicit Substances
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Does patient have history of overdose?
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Has patient ever been hospitalized due to illicit substance use in the past?
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Occupational
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Does patient receive income from disability?
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Is patient currently employed?
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Patient is Employed
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Patient is Unemployed
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Description of Current Job
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Description of Previous Job (If Applicable)
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Working F/T or P/T?
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Duration of Current Unemployment [X days/months/years]
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Duration of Current Employment [X days/months/years]
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