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Personal/Family History
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---------- Date of Birth ----------
------- Fecha de nacimiento -------
------- Fecha de nacimiento -------
------- Fecha de Nacimiento -------
First Name
Nombre
Nombre
Nombre
Last Name
Apellido
Apellido
Apellido
Month
Mes
Mes
Mes
Day
Día
Día
Día
Year
Año
Año
Año
Gender
Género
Género
Género
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Male
Female
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
TOBACCO USE
What is your current cigarette smoking status?
current
(every day)
current
(some days)
previous
never
How many packs per day do you smoke?
How many packs per day did you smoke?
<1
1
1.5
2
2.5
3
3.5
4
4+
How many years have you been smoking?
How many years did you smoke?
<1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30+
Do any of these statements apply to you?
I would like to quit
I have never tried to quit
I have tried, unsuccessfully, in the past, to quit
Please mark any tobacco products that you use:
pipe
snuff
cigars
chewing tobacco
Are you exposed to secondhand smoke?
no
minimally
frequently
daily
ALCOHOL USE
How often do you drink alcohol?
never
moderately
quit recently
occasionally
heavily
quit a long time ago
Type(s):
beer
wine
liquor
DRUG USE
How often do you use illicit drugs?
never
weekly
quit recently
socially only
monthly
quit a long time ago
daily
yearly
prefer to discuss with provider
Type(s):
crack cocaine
heroin
marijuana
cocaine
downers
IV drugs
uppers
CAFFEINE USE
Do you consume any of these?
carbonated beverages
tea
coffee
Servings per day:
none
1
2
3
4
5
6
7
8
8+
EXERCISE
Number of times you exercise each week:
none
1
2
3
4
5
6
daily
Type(s):
walking
yoga
team sports
running
stretching
yardwork
cycling
exercise classes
housework
SEATBELT USE
always
almost always
occasionally
never
PAST MEDICAL HISTORY
Please indicate if YOU have a history of the following:
Alcohol Abuse
Anemia
Anesthetic Complication
Anxiety Disorder
Arthritis
Asthma
Autoimmune Problems
Birth Defect(s)
Bladder Problems
Bleeding Disease
Blood Clots
Blood Transfusion(s)
Bowel Disease
Breast Cancer
Cervical Cancer
Colon Cancer
Depression
Diabetes
Heart Attack
Heart Disease
Heart Pain / Angina
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
High Cholesterol
HIV
Hives
Kidney Disease
Liver Cancer
Liver Disease
Lung Cancer
Lung / Respiratory Disease
Mental Illness
Migraines
Osteoporosis
Prostate Cancer
Rectal Cancer
Reflux / GERD
Seizures / Convulsions
Severe Allergy
Skin Cancer
Stroke / CVA of the Brain
Suicide Attempt
Thyroid Problems
Ulcer
Growth / Development Disorder
Sexually Transmitted Disease (STD)
Other Disease, Cancer, or Significant Medical Illness
NONE of the Above
FAMILY MEDICAL HISTORY
Please indicate which family members have had these illnesses:
FAMILY HISTORY UNKNOWN
NO SIGNIFICANT FAMILY MEDICAL HISTORY
Father
Mother
Brother
Sister
Son
Daughter
Alcohol Abuse
Anemia
Anesthetic Complication
Arthritis
Asthma
Bladder Problems
Bleeding Disease
Breast Cancer
Colon Cancer
Depression
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lung / Respiratory Disease
Migraines
Osteoporosis
Rectal Cancer
Seizures / Convulsions
Severe Allergy
Stroke / CVA of the Brain
Thyroid Problems
Other Cancer
Mother, Grandmother, or Sister developed Heart Disease before age 65.
Father, Grandfather, or Brother developed Heart Disease before age 55.
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