Medical History Form

Do you use or do you have history of using tobacco?*
If you currently smoke, how many packs per day?
If you have a history of smoking, when did you quit?
Do you drink or do you have history of drinking alcohol?*
If yes, how much and how often?
Do you have a history of abusing drugs, alcohol, or prescription drugs?*
If yes, please explain:

List conditions your family members have/had:
Mother:
Father:
Sisters:
Brothers:
Children:
Maternal Grandmother:
Maternal Grandfather:
Paternal Grandmother:
Paternal Grandfather:

When and where was your last:
Mammogram
Pap Smear
Bone Density Test
Prostate Exam
Colonoscopy
Labs
Pneumonia Vaccine
Tetanus Vaccine
Whooping Cough Vaccine
Shingles Vaccine