Patient Intake And History Form - New West Sports Page 3
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4FAMILY HISTORY
Has any member of your family been diagnosed with any of the following conditions (include deceased family
members)? Place an “X” under the correct family member with the condition, and indicate if the family member passed
away due to that condition.
Father
Mother
Father’s
Mother’s
Siblings
Children
Parents
Parents
Bleeding Disorder
________
_________
_________
_________
_________
_________
Cancer
________
_________
_________
_________
_________
_________
Diabetes Mellitus
________
_________
_________
_________
_________
_________
Heart Disease
________
_________
_________
_________
_________
_________
High Blood Pressure
________
_________
_________
_________
_________
_________
HIV Infection
________
_________
_________
_________
_________
_________
Kidney Disease
________
_________
_________
_________
_________
_________
Osteoporosis
________
_________
_________
_________
_________
_________
Stroke
________
_________
_________
_________
_________
_________
Thyroid Disease
________
_________
_________
_________
_________
_________
List any other important family medical condition(s) you are aware of (do not include common colds or flu). Include
date of initial diagnosis if possible:
Family Member
Medical Condition / Date of Initial Diagnosis
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you or anyone in your family(mother, father, sister, brother) ever had a reaction to anesthetic, general or local,
causing high fever(malignant hyperthermia), blood pressure problems, hepatitis or any other type of allergic reaction?
Yes
No
If yes, please explain:
_____
SOCIAL HISTORY:
What is your current occupation? ______________________________________________________________________
Please describe your current tobacco use:
Never a smoker
Former Smoker
Current every day smoker
Current some a day smoker
Current status unknown
Unknown if ever smoked
Do you drink alcoholic beverages?
Yes
No
If yes, please indicate what type of beverage and how many servings per day: __________________________________
Have you ever used any illicit drugs?
Yes
No
If yes, please indicate what type of drug and how often: ____________________________________________________
Please describe your highest education level attained?
Less than high school
High school graduate
Some college
College graduate
Postgraduate
Unknown
Please describe your current exercise routine:
Inactive
Light
Moderate
Vigorous
If you do have a current exercise routine, how many times per week: __________________________________________
Please describe your hobbies and interests? _____________________________________________________________
__________________________________________________________________________________________________
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