|
Father is alive
|
Father is deceased
|
|
Mother alive
|
Mother is deceased
|
|
Denies medical illness
|
|
|
Medical Illness Listing
• • •
|
|
|
Family History Relevance
|
|
|
Past Surgical History
|
|
|
Surgical Relevance
|
|
|
Left/Right handed
|
|
|
Person present in room (if appli
• • •
|
|
|
Martial Status
• • •
|
|
|
Caffeine
|
No caffeine
|
|
Alcohol
|
No alcohol
|
|
Tobacco
|
No tobacco
|
|
Employed
|
Not employed
|
|
Current Employer (Name of Compan
|
|
|
Self Employed
|
|
