|
Medical History
|
|
|
Past Medical History
• • •
|
Past Medical History Freewrite
|
|
Past Surgical History
• • •
|
Complete list of surgeries
|
|
|
|
|
Childhood illnesses
• • •
|
Comments
|
|
Childhood Immunizations
• • •
|
Comments
|
|
Date of last PE
|
Comments
|
|
PCP
|
PCP Contact Information
|
|
FAMILY HISTORY
|
|
|
Father's Medical Hx
• • •
|
Comments
|
|
Paternal Relative Hx
|
Comments
|
|
Mother's Medical Hx
• • •
|
Comments
|
|
Maternal Relative Medical Hx
|
Comments
|
|
Sibling(s)' Med Hx
• • •
|
Comments
|
|
Children(s)' MH
• • •
|
Comments
|
|
SOCIAL HISTORY
|
|
|
Occupation
|
|
|
Relationship Status
|
number of children
|
|
Does the patient smoke?
|
Comments
|
|
Alcohol
|
Comments
|
|
Caffeine
|
Comments
|
|
Other substances
|
Comments
|
|
Patient's diet
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
New Short Text Field
|
|
|
|
|
|
|
|
|
SURGICAL HISTORY
• • •
|
|
|
Marital Status
• • •
|
|
|
PAST MEDICAL HISTORY
• • •
|
|
|
|
Past surgical History details
|
|
|
|
|
Potential Environmental Pathogen
|
|
|
Sexual Hx
|
|
|
other medical problems
|
|
|
Occupation
|
|
|
|
|
