Personal / Social History
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!
Other (list below)
Limited Mental Capaticity
Dementia (Please select the appropriate level below:)MildModerateSevere
Please list all prior operations / hospitalizations (with dates)
Name of Hospital / Facility