PATIENT’S FAMILY HISTORY

NAME:_________________________________ DATE OF BIRTH_____________________________
BIRTH PLACE:__________________________

MOTHER’S AGE:___________ HER DISEASE:_______________SMOKER?_______________________

FATHER’S AGE:____________ HIS DISEASE;________________SMOKER?_______________________

KNOWN FAMILIAL DISEASE:

HABITS:_____________________
EXERCISE:__________________ HOW OFTEN? _______________________________________________
ALCOHOL:__________________ HOW MUCH? _______________________________________________
CIGARETTE:________________  HOW MANY? _______________________________________________
DRUGS:____________________
HISTORY OF ADDICTION OR DEPENDENCE: _______________________________________________
BRIEF DESCRIPTION _____________________________________________________________________
DO YOU USE SEATBELT? _________________________________________________________________
DO YOU WEAR A BIKE HELMET? _________________________________________________________
MEDICATION AND SUPPLEMENTS:_______________________________________________________
OPERATION ____________________________________________________________________________
HOSPITALIZATION:_____________________                     
ALLEGIES? _____________________ ASTHMA? _____________________ HAYFEVER?____________
YEAR OF LAST TETANUS SHOT:___________________________________
IMMUNIZATION:_____________________ ACTIVE?_____________________ SAFE? _____________
PAST MEDICAL ILLNESS OIR SERIOUS INFECTIONS: _____________________
PSYCHOLOGICAL PROBLEMS: _____________________
HIGH LEVEL OF EDUCATION ATTAINED: _____________________
DO YOU HAVE A LIVING WILL? _____________________ A HEALTH CARE PROXY? ___________
REASON FOR THE VISIT? _____________________