HOSPITALIZATION & SURGICAL HISTORY -- List all hospital admissions and operations you have had.

Reason for Hospitalization/Surgery

Year

Choose One

Yes

Did you have any problems with anesthesia? If YES, please describe.

SOCIAL HISTORY

Choose One

Yes

No

Do you currently smoke or use other tobacco products? If YES, How many per day? . . .

Choose One

Yes

No

Have you smoked or used other tobacco products in the past? If YES, How many per day?...

years since you last smoked?

Choose One

Yes

No

Do you drink caffeinated beverages? If YES, What type, how often, how much

Choose One

Yes

No

Do you drink alcohol? If YES, What type, how often, how much

Choose One

Yes

No

Do you exercise regularly? If YES, What type?

How often and how long?

FAMILY MEDICAL HISTORY -- Check the box next to any medical condition below that has affected any of your immediate family members (parents, brothers, sisters), state your relationship and their age at onset.

High Cholesterol

Heart Disease

Stroke

Migraines

Seizures/Convulsions

Diabetes

Bleeding/Blood-clotting Disorder

Allergies

Asthma

Thyroid Problems

Osteoporosis

Psychiatric Disorder/Mental Illness

Alzheimer's/Dementia

Cancer - type:

Other

Other

Relationship

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Age at onset

Next: Screening History & Symptoms

Location

10806 Reisterstown Rd, Ste 1F
Owings Mills, MD 21117

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Monday & Saturday: 10am – 4pm

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