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Past Medical History
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Past Medical History
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Other Providers Seen
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Social History
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Tobacco
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Ever smoked tobacco?
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Approximate number of pack-years
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Still smoking?
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If quit, in approximately what year?
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Consuming smokeless tobacco?
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Alcohol
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Drink alcohol presently?
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How much alcohol?
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History of heavy alcohol use?
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Illicit Substances
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Currently using illicit substances?
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Illicit substances being consumed
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Employment/Relationships
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Currently employed?
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Occupation
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Family Members (has family including...)
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Living with?
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Miscellaneous Social Details
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Family History
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Family history of colorectal cancer?
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Family history of breast cancer?
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Family history of prostate cancer?
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Family history of heart disease?
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Family History details
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