Date MM slash DD slash YYYY Last First FAMILY HISTORY Check if any of your relatives have the following and what their relation is to youArthritis, GoutNameRelationship Heart disease, StrokeNameRelationship Asthma, hay feverNameRelationship High Blood pressureNameRelationship Cancer (specify)NameRelationship Kidney diseaseNameRelationship Chemical dependencyNameRelationship TuberculosisNameRelationship DiabetesNameRelationship OtherNameRelationship HEALTH HABITS:Smoking Yes No (cigarettes, cigar or pipe)per day pack(s) per day How long have you smoked?Year(s) Month(s) Recreational drugs Yes No Homosexual habits Yes No Alcohol Yes No No of glasses or cans a day, week, month Carbonated beverages Yes No No of glasses or can(s) a day, week, month Coffee Yes No No of cups a day Tea Yes No No of cups a day HOSPITALIZATIONS: YearReasonHospital PREGNANCY HISTORY:YearComplications?Sex of child Have you ever had a blood transfusion ? Yes No Date MM slash DD slash YYYY OCCUPATION:Is there stress heavy lifting hazard ous substances other(please specify) I certify that the information that I have provided is correct to the best of my knowledge. I will not hold the Doctor or any staff member resp onsible for any errors or omissions that I may have made in the completion of this form
