Emory Healthcare Initial History Form Page 3
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5Whom do you live with? _________________________________
Who knows about your condition?_________________________
Is there anyone who should not know? _____________________
Where do you live now?__________________ Where were you born?________________________
Where in the US have you lived?_______________________________________________________
___________________________________________________________________________________
Where have you traveled abroad? ______________________________________________________
___________________________________________________________________________________
What pets do you have?_______________________________________________________________
What was your highest grade level in school? ___________
Are you currently working?
Yes
No
What is/was your occupation? _________________________________________________________
Sexuality
Do you consider yourself?
Heterosexual
Homosexual
Bisexual
Transsexual
Are you married/committed?
Yes
No
Divorced
Separated
Widowed
Do you have a steady sexual partner?
Yes
No
Have you had sex in the past three months?
Yes
No
Do you use condoms?
Never
Sometimes
Always
How many sexual partners have you had in the past 3 months? ________________
Substance Use
Do you smoke cigarettes? Never
No longer use, quit ____ Yes, average _______cigs/day
How old were you when you started smoking? _______
Do you drink alcohol?
Never
No longer use, quit ____ Yes, average ________drinks/day
Did you ever have an alcohol blackout?
Yes
No
Did you ever have a DUI?
Yes
No
Do you use Marijuana?
Never
No longer use, quit ____ Yes
How often? __________
Do you use Cocaine?
Never
No longer use, quit ____ Yes
How often? __________
Do you use Heroin?
Never
No longer use, quit ____ Yes
How often? __________
Do you use Crystal Meth? Never
No longer use, quit ____ Yes
How often? __________
Have you ever injected IV drugs?
Yes
No
Family History
Have any of your blood relatives had any of the following?
Medical Condition
Check if Yes
Relative and approximate Age
High Blood Pressure
Heart disease, MI, bypass surgery
Hyperlipidemia (high cholesterol)
Stroke
Diabetes
Cancer
Kidney disease, dialysis
Alzheimer’s disease
Autoimmune diseases (lupus,
thyroid dis, rheumatoid arthritis, etc)
Others
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Parent category: Medical