PAST MEDICAL HISTORY

SURGERIES & OVERNIGHT HOSPITALIZATIONS

ALLERGIES

CURRENT MEDICATIONS

SOCIAL HISTORY

Parents and people living with the patient:

Are the patient's parents:

Married Separated Never Married Divorced

If Divorced, how long

FAMILY HISTORY

Notes or other family member information (if cancer indicated above, please note cancer type below)

PREGNANCY & BIRTH (<1 YEAR ONLY)

Is this child yours by: Birth Adoption Stepchild Other

Gestational Age: Birth Weight: Birth Length:

Delivery: Vaginal Caesarian If Caesarian, why?

Please indicate any medical problems during pregnancy:

Please indicate any medical problems during the baby's newborn period:

	Mother	Father	Siblings	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather
Living Status (check if Living)
Asthma
Diabetes
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer
Colon Polyps
Depression