Health & PERSONAL CARE HISTORY All questions contained in this questionnaire are optional and will be kept strictly confidential. Sedentary (No exercise) Exercise Mild exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes) None Coffee Tea Soda Caffeine # of cups/cans per day? Do you drink alcohol? Yes No Alcohol If yes, what kind? How many drinks per week? Do you use tobacco? Yes No Tobacco Cigarettes – pks./day Chew - #/day Pipe - #/day Cigars - #/day # of years Or year quit Do you currently use recreational or street drugs? Yes No Drugs Have you ever given yourself street drugs with a needle? Yes No Are you sexually active? Yes No Sex Method of contraceptive or barrier method used: What is your sexual preference? Do you live alone? Yes No Personal Safety Do you have guns in the home? Yes No Do you have vision or hearing loss? Yes No Do you have an Advance Directive or Living Will? Yes No Do you wear a proper restraint in vehicle? Yes No family history (Please specify maternal or paternal) Condition Relationship to you Condition Y/N Relationship to you Y/N Anemia High Cholesterol Arthritis Kidney Stones Asthma Liver Disease Breast cancer Mitral Valve Prolapse Colon Cancer Osteoporosis Depression Rheumatic Fever Diabetes Thyroid Problems GERD/Acid Reflux Tuberculosis Gout (high uric Acid) Other Cancer Heart Disease Other Condition High Blood Pressure Other Condition
Health & PERSONAL CARE HISTORY All questions contained in this questionnaire are optional and will be kept strictly confidential. Exercise Sedentary (No exercise) Mild exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes) Caffeine None Coffee Tea Soda # of cups/cans per day? Alcohol Do you drink alcohol? Yes No If yes, what kind? How many drinks per week? Tobacco Do you use tobacco? Yes No Cigarettes – pks./day Chew - #/day Pipe - #/day Cigars - #/day # of years Or year quit Drugs Do you currently use recreational or street drugs? Yes No Have you ever given yourself street drugs with a needle? Yes No Sex Are you sexually active? Yes No Method of contraceptive or barrier method used: What is your sexual preference? Personal Safety Do you live alone? Yes No Do you have guns in the home? Yes No Do you have vision or hearing loss? Yes No Do you have an Advance Directive or Living Will? Yes No Do you wear a proper restraint in vehicle? Yes No family history (Please specify maternal or paternal) Condition Y/N Relationship to you Condition Y/N Relationship to you Anemia High Cholesterol Arthritis Kidney Stones Asthma Liver Disease Breast cancer Mitral Valve Prolapse Colon Cancer Osteoporosis Depression Rheumatic Fever Diabetes Thyroid Problems GERD/Acid Reflux Tuberculosis Gout (high uric Acid) Other Cancer Heart Disease Other Condition High Blood Pressure Other Condition
New_Patient_Packet_USE_2.docx