|
Medical History
|
|
|
Past Medical History
• • •
|
Additional Medical Notes
|
|
Past Surgical History
• • •
|
Additional surgical notes
|
|
PCP
• • •
|
Last Routine Physical with PCP
• • •
|
|
Colonoscopy
• • •
|
PSA Lab Testing
• • •
|
|
|
|
|
Family History
|
|
|
Father's MH
• • •
|
Mother's MH
• • •
|
|
Children(s)' MH
• • •
|
Additional Notes
|
|
|
|
|
Social History
|
|
|
Marital Status
• • •
|
Occupation
|
|
Pt has Children
• • •
|
Pt wants future children
• • •
|
|
Caffeine
|
Alcohol
|
|
Substance use
• • •
|
DIET
• • •
|
|
Exercise
• • •
|
Nicotine Use
• • •
|
