Patient Medical Information
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Name:
________________________________
DOB: ____/____/______
Occupation:
________________________________
Education:
________________________________
Marital Status:
Single / Married / Divorced / Widowed
Tobacco Product Use:
None / Current Use / Past Use
Type of Product:
________________________________
How much per day?
________________________________
For how long?
________________________________
Daily caffeine consumption?
Yes / No
How much per day? ______
Alcohol Use?
Yes / No
How much per day?
________________________________
Do you currently exercise?
Yes / No
How often? ________
What type?
________________________________
________________________________
________________________________
Females:
Number of pregnancies _____
Number of Live Births _____
Type of delivery ________
Medication Allergies:
________________________________
Other Allergies:
________________________________
Medications:
________________________________
Current Medical Problems:
________________________________
Past Medical Problems:
________________________________
Family Medical History:
________________________________
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