ItltCALDWELL ,'· HEALTH ISSUES UNC HEALTH CARE TOBACCO Smoke Cigarettes? y N (If you never smoked, please move to Alcohol /Drug Use) · . · I Current: Packs/day #of Years Past: Quit Date: Packs/day #of Years Other Tobacco 0 Pipe 0 Cigar 0 Snuff OChew (check one): I .. I ALCOHOL/DRUG USE Do you alcohol? N 0 y ··. Beer 0 vyine. O ·Liquqr #of Dril1ks/week: Do you use marijuana or recreational drugs? y N Have you ey r_used needles to inject drugs? YN \'N H ve you ever someone else's drugs? I S ?<UAL fiiSTORY Sexually involved currently? N y (If you are a virgin, please move to Excercise) 0 Sexual partner(s) is/are/have been: Male 0 Female Birth control method:O None Ocondom 0 Piii/Ring/Patch/lnj/IUD 0 Vasectomy .. .. I tc;, EXERCISE · Do you exercise regularly? N y (If you answered no, please rnove Sjeep) .. What kind of exertise? Duration: How long (min.) : .. i-lowoften: .. I if LE,EP How many on average, do you sleep at night (or during the day, working night shift)? I I ·ottr' 0 How would you rate your diet? 0 GoodOFair Poor Wot..MVo li e advice on your diet? YN I Do you use seat consistently? N y SAFETY Do you use a bike helmet? y N Working smoke detector in home? YN If you have guns at home, are they locked up? YN Have you completed an Advance Directive for Health Care Is violence at home a concern for you? YN (ADHC), LivingWill, or Physical OrdersforlifeSustainingTherapy (POLST)? Y N OTHER PROVIDERS/SPECIALISTS SPECIALIST NAME LAST viSIT Cardiology Gastroenterologist (GI) OB/GYN Neurology Pulmonary ADDITIONAL INFORMATION 30 Have you traveled outside of the country in the last days? y N If yes, where? Have you served in the military? y N If yes, how long and whatbranth? N Were you deployed? y If yes, where?
,'· HEALTH ISSUES ItltCALDWELL UNC HEALTH CARE TOBACCO Smoke Cigarettes? y N (If you never smoked, please move to Alcohol /Drug Use) · . · Current: Packs/day #of Years I Past: Quit Date: Packs/day #of Years Other Tobacco (check one): 0 Pipe 0 Cigar 0 Snuff OChew ALCOHOL/DRUG USE I Do you alcohol? y N .. 0 ··. Beer 0 vyine. O ·Liquqr I #of Dril1ks/week: Do you use marijuana or recreational drugs? y N Have you ey r_used needles to inject drugs? YN H ve you ever someone else's drugs? \'N S ?<UAL fiiSTORY I Sexually involved currently? y N (If you are a virgin, please move to Excercise) Sexual partner(s) is/are/have been: 0 Male 0 Female Birth control method:O None Ocondom 0 Piii/Ring/Patch/lnj/IUD 0 Vasectomy .. .. EXERCISE I · Do you exercise regularly? y N (If you answered no, please rnove tc;, Sjeep) What kind of exertise? .. Duration: How long (min.) : .. .. i-lowoften: LE,EP I How many on average, do you sleep at night (or during the day, if working night shift)? ·ottr' I How would you rate your diet? 0 GoodOFair 0 Poor I Wot..MVo li e advice on your diet? YN SAFETY I Do you use a bike helmet? y N Do you use seat consistently? y N Working smoke detector in home? YN If you have guns at home, are they locked up? YN Is violence at home a concern for you? YN Have you completed an Advance Directive for Health Care (ADHC), LivingWill, or Physical OrdersforlifeSustainingTherapy (POLST)? Y N OTHER PROVIDERS/SPECIALISTS SPECIALIST NAME LAST viSIT Cardiology Gastroenterologist (GI) OB/GYN Neurology Pulmonary ADDITIONAL INFORMATION Have you traveled outside of the country in the last 30 days? y N If yes, where? Have you served in the military? y N If yes, how long and whatbranth? Were you deployed? y N If yes, where?
New%20Patient%20Packet%202018%20-%20Anderson(1).docx