Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Birth Sex
Male
Female
Undifferentiated
Current Gender Identity
Male
Female
Choose not to disclose
Female to Male/Transgender Male
Genderqueer
Male to Female/Transgender Female
Preferred Pronoun
Decline to answer
He, Him, His
She, Her, Hers
They, Them, Theirs
Ze, Hir
Other
If other was selected, please specify below
Marital Status
Single
Married
Widow (er)
Partner
Divorced
Who do you live with?
Alone
Partner
Family
Other
Ethnicity
Alaskan Native or American Indian
African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Unknown
Other
Declined
If other was selected, please specify below
Primary Language
English
Spanish
Other
Declined
If other was selected, please specify below
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
Emergency Contact
First Name
Last Name
Occupation
Phone
(###)
###
####
Pharmacy Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Insurance Policy Name Holder
Insurance Policy Number
Medications
Allergies
Past Medical History
Past Surgeries
Alcohol Use
Yes
No
Former
Tobacco Use
Yes
No
Former
Tobacco Type
Cigarette
Cigar
Smokeless tobacco/Cape
Chewing tobacco
Packs/Cigars per day
How many years smoking
Caffeine
None
Coffee
Pop/Soda
Energy drinks
Other
How much per week?
Recreational Drug Use
Yes
No
Former
Have you ever used IV drugs?
Yes
No
Are you currently sexually active?
Yes
No
Any history of sexually transmitted diseases
Yes
No
Do you wear your seatbelts when driving?
Yes
No
Do you have difficulty dressing yourself?
Yes
No
Do you have difficulty carrying 10 pounds?
Yes
No
Have you had any falls you in the last year?
Yes
No
If yes, how many falls in the past year?
Were you injured in the fall?
Yes
No
Do you exercise?
Yes
No
Are there any guns present in your home?
Yes
No
How hours per week of exercise?
Little interest in doing things
Not at all
Several days
More than half the days
Nearly daily
Feeling down, depressed or hopeless
Not at all
Several days
More than half the days
Nearly daily
Do you have a Living Will/Durable Power of Attorney?
Yes
No
How many children do you have?
1
2
3
4
5
6
7
Family History:
Vaccination History:
How many pregnancies?
1
2
3
4
5
6
7
8
9
10
How many live births?
1
2
3
4
5
6
7
8
9
10
First day of last menstrual period
MM
DD
YYYY
Do you use any form of birth control?
Yes
No
If yes, which form of birth control?
Date of last Pap Smear
MM
DD
YYYY
Any abnormal PAP Smears?
Yes
No
If yes, what are the results and the date?
Date of last mammogram
MM
DD
YYYY
Was the mammogram abnormal?
Yes
No
If yes, what are the rests and the date?
Name
First Name
Last Name
Date
MM
DD
YYYY
Have there been any changes to your family or social situation?
Yes
No
What type of child care do you use?
Option 1
Option 2