PAST MEDICAL, FAMILY AND SOCIAL HISTORY FORM. PAST MEDICAL HISTORY COMMON DISEASES Do you have a personal history of any of the following?

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1 PAST MEDICAL, FAMILY AND SOCIAL HISTORY FORM Name: (Last, First, M.I.) M F DOB: PAST MEDICAL HISTORY COMMON DISEASES Do you have a personal history of any of the following? Kidney Disease Diabetes High Blood Pressure Ischemic Heart Disease Cancer Stroke Gout CKD Stage: Transplant Cadaveric Living - Related Living - Unrelated Type 1 Type 2 Essential Renovascular Heart attack Angina Angioplasty Lung Breast Prostate Colon Melanoma Bladder Stroke Gout Dialysis D PD Polycystic Kidney Disease Acute Kidney Injury Glomerulonephritis Type Unknown White Coat Hypertension Conn s Syndrome Coronary Stent CABG (Coronary Artery Bypass Graft) Lymphoma Kidney Thyroid Leukemia Endometrial Pancreatic PAST MEDICAL HISTORY ADDITIONAL CONDITIONS Do you have a personal history of any of the following? Blindness Hearing Problems EENT Cataracts Glaucoma Cardiovascular Respiratory Atrial Fibrillation Pacemaker AICD (Cardiac Defibrillator) COPD Chronic Bronchitis Asthma Emphysema Valvular Heart Disease Congestive Heart Failure Mitral Valve Prolapse Pneumonia Tuberculosis Sleep Apnea

2 GERD (Gastric Reflux) Stomach/Bowel Ulcers Gastrointestinal Gall Bladder Disease Hepatitis Genitourinary Enlarged Prostate Kidney Stones OB History Preeclampsia Pregnancy Induced Hypertension Musculoskeletal Osteoarthritis Neurological Multiple Sclerosis Seizures Inflammatory Bowel Disease Irritable Bowel Syndrome Gluten Intolerance Lactose Intolerance Frequent UTIs (Urinary Tract Infections) Gestational Diabetes History of Complicated Pregnancy Osteoporosis Parkinson s Dementia Psychiatric Depression Anxiety Disorder Endocrine Hypothyroidism Adrenal Insufficiency Hyperthyroidism Hematology Anemia Sickle Cell Disease Sickle Cell Trait Immuno/Allergy HIV AIDS Blood Transfusion Thalassemia Rheumatoid Arthritis Lupus PAST MEDICAL HISTORY SURGERY HISTORY Have any of the following surgeries been performed on you? Appendectomy CABG Carotid Endarterectomy Cataract Surgery D & C Gall Bladder Removal Gastric Bypass Hemorrhoidectomy Hernia Repair Hip Replacement Left Bilateral Right Knee Replacement Left Bilateral Right Hysterectomy Prostatectomy Nephrectomy Other Health Problems Not Listed Above: Renal Transplant Thyroidectomy Tonsillectomy Valve Replacement AV Fistula AV Graft PD Catheter Other

3 FAMILY HISTORY ILLNESSES Do the following family members have any of the following medical conditions? Kidney Disease Diabetes High Blood Pressure Ischemic Heart Disease Cancer Stroke Gout ADPKD Dementia FAMILY HISTORY STATUS Father Mother Living Living Deceased Age at Death: Cause of Death: Deceased Age at Death: Cause of Death: Other Family History Not Listed Above:

4 SOCIAL HISTORY GENERAL Current Marital Status Living Arrangement Occupation Married Separated Single Alone Family Member Spouse Retired Unemployed Employed Full - time Part - time Student Widowed Divorced In Home Caregiver Significant Other Assisted Living Facility List your Current or Former Occupation: Deficits Hearing Loss Limited Mobility Poor Vision or Blindness Transportation Challenges SOCIAL HISTORY HABITS Cigarettes Chewing Tobacco Pipes Snuff Cigars Tobacco Use If a current or former user, what year did you start?

5 Complete the following section if you are a current or former cigarette user: How often do you currently smoke or how often did you smoke before you quit? Every Day Some Days How many packs per day do you currently smoke or how many packs per day did you smoke before you quit? How many total years have you used cigarettes? Alcohol Use Occasional 1-2 per Day 3 or more per Day Recreational Drug Use Marijuana Amphetamines LSD Heroin Ecstasy Opium Cocaine Barbiturates Other Other Social History Not Listed Above:

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