|
Medical History
|
Patients Info
|
|
Past Medical History
• • •
|
Past Medical History Comments
|
|
Hospitalization History:
|
|
|
Past Surgical History:
• • •
|
Past Surgical History Comments
|
|
Immunization Status:
|
Immunization Comments:
|
|
Gyne History:
|
|
|
Gynecologic history
• • •
|
Comments: (Other)
|
|
Family History
|
Unremarkable
|
|
Father's MH
• • •
|
Comments
|
|
Mother's MH
• • •
|
Comments
|
|
|
Comments
|
|
|
Comments
|
|
Social History
|
|
|
Marital Status
• • •
|
Marital Status Comments:
|
|
Living Arrangements
• • •
|
Living Arrangement Comments:
|
|
Previous Occupation:
• • •
|
Occupation; free text
|
|
Alcohol Use
• • •
|
Alcohol use comments:
|
|
Tobacco
• • •
|
DNR
|
|
Caregiver/Home Health Agency
|
Current Services
• • •
|
|
Care Needed
• • •
|
|
