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Past Medical History:
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Patient Denies Relevant Medical History
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Patient Did not disclose medical history
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Past Medical History
• • •
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Past medical history free write
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Past Surgical History:
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The patient did not disclose any Surgical History
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Previous Spine Surgery?
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If yes- describe surgery (include surgeon/location/dates)
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Other- Non-Spine Surgery Freewrite
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Family History:
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Denies Relevant Family History
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The patient did not disclose any Family Medical History
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Family History
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Social History:
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Marital Status
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Employment Status
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Occupation (Optional)
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Smoking Status
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Free text
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Alcohol Status
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Free Text
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Illicit/Recreational Drug Use
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Free Text
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