_________________________________________ _______________________________________ Patient’s Full Name Date Of Birth ____________________________ Social Security Number SOCIAL HISTORY Smoking status : Non Smoker Former Smoker Current Smoker Other Tobacco Use □ □ □ □ Alcohol use : Non Drinker Occasional Drinker Moderate Drinker Heavy Drinker □ □ □ □ IMMUNIZATION HISTORY Flu shot Administered by: _______________________ Date administered:___________ Pneumonia Administered by: _______________________ Date administered:___________ ELECTRONIC HEALTH SUMMARY: Email Address: _____________________________________ No email Other □ □ Race Ethnicity Language □ □ American Indian or Alaska Native English □ □ □ Asian Hispanic or Latino Spanish □ □ Black or African American French □ □ □ Hispanic Not Hispanic or Latino Italian □ □ Native Hawaiian or Pacific Islander Russian □ □ □ White or Caucasian Refused to report Indian □ □ Refused to report Other ________________ □ Other Race __________________
_________________________________________ _______________________________________ Patient’s Full Name Date Of Birth ____________________________ Social Security Number SOCIAL HISTORY Smoking status : □ Non Smoker □ Former Smoker □ Current Smoker □ Other Tobacco Use Alcohol use : □ Non Drinker □ Occasional Drinker □ Moderate Drinker □ Heavy Drinker IMMUNIZATION HISTORY Flu shot Administered by: _______________________ Date administered:___________ Pneumonia Administered by: _______________________ Date administered:___________ ELECTRONIC HEALTH SUMMARY: Email Address: _____________________________________ □ No email □ Other Race Ethnicity Language □ American Indian or Alaska Native □ English □ Asian □ Hispanic or Latino □ Spanish □ Black or African American □ French □ Hispanic □ Not Hispanic or Latino □ Italian □ Native Hawaiian or Pacific Islander □ Russian □ White or Caucasian □ Refused to report □ Indian □ Refused to report □ Other ________________ □ Other Race __________________
AKI-Consents-4.17.18.docx