HOSPITALIZATIONS Reason for Hospitalization Date of Hospitalization Hospital/Physician SURGICAL HISTORY Type of Surgery Date of Surgery Hospital/Physician Procedures Date of Procedure Hospital/Physician (Colonoscopy, Catheterizations, etc.) Colonoscopy Heart Catheterization Other: FAMILY HISTORY Alive? Birth Year Age at Cause of death Father Yes No Mother Yes No How many? # Alive Birth Year(s) If deceased, age and cause of Death Brother(s) Sister(s) Children: Sons Daughters SOCIAL HISTORY Occupation: Marital Status: Single Married Separated Divorced Widowed Hobbies/Recreation: (please list) Frequency Quantity Type For Past Use: Date Quit Exercise: Yes No Tobacco: Never Present Past Alcohol: Never Present Past Caffeine: Yes No Drug Use: Never Present Past IMMUNIZATIONS Date of Last Tetanus: Date of Last Pneumovac: Date of Last Flu Vaccine: Date of Last Shingles Vaccine: MEDICAL PROVIDERS Name: Specialty: Phone No.: Name: Specialty: Phone No.: Name: Specialty: Phone No.: Signature: Printed Name: Date:
HOSPITALIZATIONS Reason for Hospitalization Date of Hospitalization Hospital/Physician SURGICAL HISTORY Type of Surgery Date of Surgery Hospital/Physician Procedures (Colonoscopy, Catheterizations, etc.) Date of Procedure Hospital/Physician Colonoscopy Heart Catheterization Other: FAMILY HISTORY Alive? Birth Year Age at Cause of death Father Yes No Mother Yes No How many? # Alive Birth Year(s) If deceased, age and cause of Death Brother(s) Sister(s) Children: Sons Daughters SOCIAL HISTORY Occupation: Marital Status: Single Married Separated Divorced Widowed Hobbies/Recreation: (please list) Frequency Quantity Type For Past Use: Date Quit Exercise: Yes No Tobacco: Never Present Past Alcohol: Never Present Past Caffeine: Yes No Drug Use: Never Present Past IMMUNIZATIONS Date of Last Tetanus: Date of Last Pneumovac: Date of Last Flu Vaccine: Date of Last Shingles Vaccine: MEDICAL PROVIDERS Name: Specialty: Phone No.: Name: Specialty: Phone No.: Name: Specialty: Phone No.: Signature: Printed Name: Date: