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PERSONAL SURGICAL/HOSPITALIZATION HISTORY

SURGERY CONDITION

YEAR/HOSPITAL

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

PERSONAL / SOCIAL HISTORY:

ARE YOU MARRIED___________ SINGLE

_______

WIDOWED_______

DIVORCED

_________

DO YOU SMOKE?

AMOUNT?

HOW LONG?

______

____________

____________

D O Y O U D R I N K A L C O H O L I C B E V E R A G E S ? _ _ _ _ _ _ _ _

AMOUNT?

___________

HOW OFTEN?

_______

DO YOU USE RECREATIONAL / ILLEGAL DRUGS?

____________________________________________ WHAT TYPE? ___________________________ HOW OFTEN? _____________________________________ (MARIJUANA, COCAINE/AMPHETAMINES, OPIATES, PRESCRIPTIONS MEDICATION ABUSE)

DO YOU DRINK CAFFEINATED BEVERAGES?

___________________________________________

WHAT TYPE? HOW OFTEN?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

DO YOU EXERCISE REGULARLY?

_______________________________________________________ RECREATIONAL ACTIVITIES? _________________________________________________________

DO YOU CURRENTLY PRACTICE ANY DIET RESTRICTIONS?

______________________________

(CIRCLE ALL THAT APPLY)

LOW SUGAR

CARDIAC DIET

WEIGHT LOSS DIET

LOW SODIUM

NEUTROPENIC DIET

KETOGENIC

LOW FAT

VEGETARIAN

GLUTEN FREE

LOW CARB

DIABETIC DIET

DAIRY RESTRICTED

HAVE YOU EVER BEEN A VICTIM OF PHYSICAL ABUSE RESULTING IN INJURIES?

____________

____________________________________________________________________________________________

HAVE YOU EVER HAD A MOTOR VEHICLE ACCIDENT RESULTING IN INJURIES?

____________

____________________________________________________________________________________________

HAVE YOU HAD ANY OTHER TYPE OF ACCIDENT OR INJURY THAT WE SHOULD BE AWARE OF? _______________________________________________________________________________________

ARE THERE ANY UNUSUAL STRESS OR SAFETY ISSUES WE SHOULD BE AWARE OF?

_________

____________________________________________________________________________________________

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