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Social History
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Marital Status
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Living Arrangements
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Comments
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Family
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Birth Control
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Comments
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Occupation
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Comments
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Stress of job
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Activity at work
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Commute to work each way
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Comments
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Lifestyle and Nutrition History
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Check Your Weight
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Comments
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Fast food habit
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Comments
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Non-Fast food take out or eating out
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Comments
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Eating At Home
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Comments
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Alcohol
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Alcohol consumption?
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Comments
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Average number of alcoholic drinks daily
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Comments
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Average number of alcoholic drinks on weekends
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Comments
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Do you use alcohol to help cope with anxiety, depression or insomnia?
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Comments
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Are you concerned about your alcohol intake?
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Comments
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h/o ETOH abuse.
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Comments
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Tobacco
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Do you smoke, chew or vape tabacco?
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Amount
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Quit Date
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Past smoking amount
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Other Substance use
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h/o of drug abuse
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Comments
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active drug use
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Comments
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