FAMILY & SOCIAL HISTORY FORM

FamilyHistory:

Patient’s Father: □ Alive □ Deceased □ Unknown

Father died of: □ Natural Causes □ Disease □ Accident □ Unknown

Father’s Age at death: ________

Patient’s Mother: □ Alive □ Deceased □ Unknown

Mother died of: □ Natural Causes □ Disease □ Accident □ Unknown

Mother’s Age at death: ________

Family History of Alcoholism	□ Yes □ No
Family History of Arthritis	□ Yes □ No
Family History of Asthma	□ Yes □ No
Family History of Bleeding disorder	□ Yes □ No
Family History of Breast Cancer	□ Yes □ No
Family History of Cervical Cancer	□ Yes □ No
Family History of Heart Disease	□ Yes □ No
Family History of Colon Cancer	□ Yes □ No
Family History of Colon Polyps	□ Yes □ No
Family History of Depression	□ Yes □ No
Family History of Diabetes	□ Yes □ No
Family History of CVA or Stroke	□ Yes □ No
Family History of Hypertension	□ Yes □ No
Family History of Hyperlipidemia	□ Yes □ No
Family History of Lung Cancer	□ Yes □ No
Family History of Melanoma	□ Yes □ No
Family History of Migraine	□ Yes □ No
Family History of Osteoporosis	□ Yes □ No
Family History of Ovarian Cancer	□ Yes □ No
Family History of Pancreatic Cancer	□ Yes □ No
Family History of Prostate Cancer	□ Yes □ No
Family History of Renal Disease	□ Yes □ No
Family History of Seizures	□ Yes □ No
Family History of Skin Cancer	□ Yes □ No
Family History of Thyroid Disease	□ Yes □ No
Family History of Huntington’s Disease	□ Yes □ No
Family History of Learning Disabilities	□ Yes □ No

SocialHistory:

Occupation: ________________________Job Duration(yrs):___________

Education Level: □ High School partial □ High School

□College partial □ College Graduate □ Post-graduate □ Doctural

Hobbies, Interests,Pets:

________________________________________________________________

Marital Status: □ Single □ Married □ Divorced □ Widowed

Years Married: __________ Number of Children: ________

Do you have anyhistory of domestic abuse? □ Yes □ No

Does your religionrestrict or limit medical care? □ Yes □ No

RiskFactors:

Tobacco Use: □ Current □ Quit □ Never

Cigarettes: □ Yes □ No _________packs/day

Cigars: □ Yes □ No _________#/week

Smokeless: □ Yes □ No _________perday

Passive Smoke Exposure: □ Yes □ No

Drug Use: □ Yes □ No

Substance: ___________________________

HIV High Risk Behavior: □ Yes □ No

Alcohol Use: □ Yes □ No

Type: ______________________________ _________drinks/day

Do you feel the need to cut down? □ Yes □ No

Have you been annoyed by complaints? □ Yes □ No

Do you feel guilty about your drinking? □ Yes □ No

Have you ever needed an eye opener in the a.m.? □ Yes □ No

Caffeine Use: □ Yes □ No _________drinks/day

Exercise: □ Yes □ No _________times/week