,. ' UNC HEAL'I'H CARE FAMILY MEDICAL HISTORY [] NO SIGNIFICANT FAMILY HISTORY IS KNOWN Q) ·.!J.I ...... SOCIAL HISTORY Occupation 0 Retired 0 Unemployed 0 LOAD Disabled (or prior occupation): -- ·• -- gree: Years qfEducation or '·Highest.t> Eil;iptoyer: . If employed, do you work the night shift? N N/A y MaritaiStatus(checkQne):OSingle 0 Partner 0 Married D r;>hiorced D\f\fide>wed 0 Other: Do you have children? N If yes, how many? y Reli i()ll: .
,. ' UNC HEAL'I'H CARE FAMILY MEDICAL HISTORY [] NO SIGNIFICANT FAMILY HISTORY IS KNOWN Q) ·.!J.I ...... SOCIAL HISTORY Occupation (or prior occupation): 0 Retired 0 Unemployed 0 LOAD Disabled -- -- Eil;iptoyer: . ·• Years qfEducation or '·Highest.t> gree: If employed, do you work the night shift? y N N/A MaritaiStatus(checkQne):OSingle 0 Partner 0 Married D r;>hiorced D\f\fide>wed 0 Other: Do you have children? y N If yes, how many? Reli i()ll: .
New%20Patient%20Packet%202018%20-%20Anderson(1).docx