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Personal Information
Medical History
Medications
Settings
Help
Allergies
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Vaccination History
Last Tetanus Booster of TdaP
Last Flu Vaccine
Last Zoster Vaccine (Shingles)
Last Phuemovax (Pneumonia)
Last Prevnar
Personal Medical History
Disease/Condition
Current
Past
Comments
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Surgeries
Type
Date
Location/Facility
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Womens Health History
Date of Last Menstrual Cycle
Total Number of Pregnancies
Pregnancy Complications
Age of First Menstruation
Age of Menopause
Family Medical History
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Social History
Occupation
Employer
If employed do you work the night shift?
Do You Have Children?
Years of Education or Highest
Other Health Issues
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Tobacco Use
Smoke Cigarettes?
Yes
No
Current: Packs/day
# of Years
Past: Quit Date
Other Tobacco
Pipe
Cigar
Snuff
Chew
Sexual Activity
Sexually involved currently?
Yes
No
Sexual partner(s) is/are/have been:
Male
Female
Birth control method:
None
Condom
Pill/Ring/Patch/Inj/IUD
Vasectomy
Advance Directive
Have you completed an Advance Directive for Health Care (ADHC), Living Will, or Physical Orders for Life Sustaining Therapy (POLST)?
Yes
No
Other Providers/Specialists and Last Visit
Cardiology
Gastroenterologist (GI)
OB/GYN
Neurology
Pulmonary
Other:
Other:
Additional Information
Have you traveled outside of the country in the last 30 days?
Yes
No
Have you served in the military?
Yes
No
Were you deployed?
Yes
No
Sleep
How many hours, on average, do you sleep at night (or during the day, if working night shift)?
Exercise
Do you Exercise Regularly?
Yes
No
What Kind of Exercise?
How often?
How long (min)?
Diet
How Would You Rate Your Diet?
Good
Fair
Poor
Safety
Do You Use a Bike Helmet?
Yes
No
Do You Use Seat Belts Consistently?
Yes
No
Working Smoke Detector in Home?
Yes
No
Is Violence at Home a Concern For You?
Yes
No
If You Have Guns at Home, Are They Locked Up?
Yes
No
Historical Information Tracking
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Plan Name
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