None Coffee Tea Soda Caffeine # of cups/cans/bottles per day Do you currently use recreational or street Yes No Drugs Have you ever given yourself street drugs with a needle? Yes No Do you drink alcohol? Yes No Alcohol If yes, what kind? How many drinks per week? Are you concerned about the amount you drink? Yes No Have you considered stopping? Yes No Have you ever experiences blackouts? Yes No Are you to drinking? Yes No “binge” Do you use tobacco? Yes No Tobacco Cigarettes pks/day Chew - #/day Pipe - #/day Cigars - #/day – # of years smoking Or quit year Do you live alone? Yes No Personal Safety Do you have frequent falls? Yes No Do you have vision or hearing loss? Yes No Do you have an Advance Directives and/or living will? Yes No Would you like information on the preparation of these? Yes No Physical and/or mental abuse have also become major public health Yes No issue in the country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with the provider? HEALTH HISTORY (Do you currently have or have you ever had any of the following): Past Medical History Diabetes High Blood Pressure Condition Seizures Blood Disorder Clots Stroke Cancer Asthma Mitral Valve Prolapse Heart Attack Other: (heart murmur) (Have you had any of the following surgeries): Past Surgical History Hysterectomy Bladder Surgery Surgery for Urinary Incontinence Surgery on the Ovaries Endometriosis Surgery C-Section Tubal Ligation Appendectomy Gallbladder Surgery Ectopic Pregnancy Hernia Surgery Cancer Surgery Other: Other: Other: (Choose all illnesses that a member of your family has/had): Family Medical History High Blood pressure Diabetes Uterine Cancer Ovarian Cancer Cervical Cancer Colon or Rectal Cancer Breast Cancer Other: Other:
Caffeine None Coffee Tea Soda # of cups/cans/bottles per day Drugs Do you currently use recreational or street Yes No Have you ever given yourself street drugs with a needle? Yes No Alcohol Do you drink alcohol? Yes No If yes, what kind? How many drinks per week? Are you concerned about the amount you drink? Yes No Have you considered stopping? Yes No Have you ever experiences blackouts? Yes No Are you to “binge” drinking? Yes No Tobacco Do you use tobacco? Yes No Cigarettes – pks/day Chew - #/day Pipe - #/day Cigars - #/day # of years smoking Or quit year Personal Safety Do you live alone? Yes No Do you have frequent falls? Yes No Do you have vision or hearing loss? Yes No Do you have an Advance Directives and/or living will? Yes No Would you like information on the preparation of these? Yes No Physical and/or mental abuse have also become major public health issue in the country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with the provider? Yes No HEALTH HISTORY Past Medical History (Do you currently have or have you ever had any of the following): Diabetes High Blood Pressure Condition Seizures Blood Disorder Clots Stroke Cancer Asthma Mitral Valve Prolapse (heart murmur) Heart Attack Other: Past Surgical History (Have you had any of the following surgeries): Hysterectomy Bladder Surgery Surgery for Urinary Incontinence Surgery on the Ovaries Endometriosis Surgery C-Section Tubal Ligation Appendectomy Gallbladder Surgery Ectopic Pregnancy Hernia Surgery Cancer Surgery Other: Other: Other: Family Medical History (Choose all illnesses that a member of your family has/had): High Blood pressure Diabetes Uterine Cancer Ovarian Cancer Cervical Cancer Colon or Rectal Cancer Breast Cancer Other: Other:
Registration-Packet-and-Medical-History-6-Pages.docx