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Family Practice Associates
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Social Educational and Work History
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Name
*
Today's Date
*
Do you have children?
Name
*
Marital Status
Age of children, if any
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Work Status : Employed/Unemployed/Retired/Disabled , Place of employment
Current or Prior Occupation:
Hours worked per week
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Highest Level of Education
Completed at which institution / school
What type of exercises do you perform, duration and frequency?
In what type of residence do you live (i.e, house, assisted living nursing home)?
What are your hobbies?
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Do you drink alcohol?
Yes
No
What type of alcohol?
No. of drinks per week?
Selected Value:
0
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Are you a current smoker?
Yes
No
How many packs per day?
Selected Value:
0
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Are you a former smoker?
Yes
No
On average, how much did you smoke per day?
Selected Value:
0
If so, what year did you quit?
No. of years you smoked?
Selected Value:
0
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Are you sexually active
Yes
No
Are you concerned that you may have been exposed to HIV?
Yes
No
Do you have sex with?
How many partners have you had during the past 12 months?
Selected Value:
0
Family Health History
Please list below the health history of your blood (genetic) first degree relatives
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Mother
Living or Deceased
Living
Deceased
Cause of Death
Current age or age at death
Health problems
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Father
Living or Deceased (copy)
Living
Deceased
Cause of Death
Current age or age at death
Health problems
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Brother(s)
Living or Deceased (copy) (copy)
Living
Deceased
Cause of Death (copy)
Current age or age at death (copy)
Health problems (copy)
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Sister(s)
Living or Deceased (copy) (copy) (copy)
Living
Deceased
Cause of Death (copy) (copy)
Current age or age at death (copy) (copy)
Health problems (copy) (copy)
Review of Symptoms
Please review the following symptoms and circle those items that are a problem for you
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Vision Problems
Wheezing
Lumps in Breast
Frequent Urination
Excessive Hunger
Hearing Problems
Asthma / COPD
Breast discharge
Incontinence
Excessive Thirst
Sinus Trouble
Emphysema
Trouble swallowing
Blood in Urine
Weakness
Hay Fever
Bronchitis
Nausea
History of STD's
Fatigue
Nosebleeds
TB Exposure
Vomiting
Anemia
Fever / Sweating
Sore Throat
Chest Pain
Abdominal pain
Easy Bruising
Fainting
Hoarseness
Chest Discomfort
Hepatitis / Jaundice
Pain in Legs
Seizures / Tremor
Lumps in Neck
Shortness of Breath
Gallstones
Joint Pain / Stiffness
Headaches
Tooth Problems
High blood pressure
Diarrhea
Blood clot
Numbness/Tingling
Cough
Diabetes
Constipation
Weight loss / Pain
Anxiety/Depression
Coughing blood
High Cholesterol
Blood in stool
Heat/cold intolerance
Difficult sleeping
Disease Prevention and Health Maintenance
Please list below the most recent dates of vaccines and health screening tests
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Flu Vaccine
Mammogram
Eye Exam
Pneumonia Vaccine
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Pap Smear
Heart Catheterization
Tetanus Vaccine
Colonoscopy
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Endoscopy (EGD)
Hepatitis B Vaccine
Bone Density
Heart Stress Test
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Shingles Vaccine
EKG
Ab Aneurism Screen
Gardasil Vaccine
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Chest X-Ray
HIV Test
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Patient Name
*
Electronically Signed
*
I Agree
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.
Date of Birth
*
Date / Time
*
Date
Time
Submit