Personal / Social History

MarriedDivorcedWidowedSingle
Previous Occupation
History of Smoking:     YES      NO     If YES, How much? 
If you have quit smoking, when? 
History of Alcohol Use:     YES      NO      If YES, How Often?
History of Drug Abuse:     YES      NO      If YES, explain
Food or Drug Allergies:     YES      NO      If YES please list and state your reaction!
Family History

 Hypertension
 Diabetes
 Cancer
 COPD
 Blood Disease
 Other (list below)
Functional Limitations
 Limited Mental Capaticity
 Dementia (Please select the appropriate level below:)MildModerateSevere

Past & Current Medical History
Please check the boxes that apply:  

Surgical History Please list all prior operations / hospitalizations (with dates)
Type of Surgery	Where Name of Hospital / Facility	Date
Type of Surgery	Location	Surgery Date
Type of Surgery	Location	Surgery Date
Type of Surgery	Location	Surgery Date
Type of Surgery	Location	Surgery Date

Last Hospital Vist 
Year & Why?