Adult Health History Page 6
ADVERTISEMENT
1
2
3
4
5
6
7
8
9N O R T H E R N N E V A D A
HOPES
your partner in health.
OTHER HEALTH ISSUES
Tobacco Use
Condom, pill, diaphragm, vasectomy, other
____________________________________
Smoke cigarettes:
Yes No
Never (If you never smoked, please skip to
Exercise
alcohol section)
Do you exercise regularly?
Yes No
Quit Date:
How many years did you smoke? ___________
What kind of exercise?
How many packs a day did you smoke? _______
_______________________________________
_______________________________________
Current smoker:
_______________________________________
Packs per day: ______________
Number of years: ______________
How long (minutes): ______________________
How often: _____________________________
Oher tobacco:
Pipe Cigar Snuff
Chew
Diet
How would you rate your diet?
Alochol Use
Good Fair
Poor
Do you drink alcohol?
Would you like advice on your diet?
Yes No
Yes No
Number of drinks per week: _____________
Beer Wine
Liquor
Safety
Do you use a bike helmet?
Drug Use
Yes No
No bike
Have you used marijuana or recreational drugs?
Yes No
Do you use seatbelts consistently?
Yes No
Have you ever used needles to inject drugs?
Yes No
Does your home have a working smoke
detector?
Sexual Activity
Yes No
Sexually involved currently?
Yes No
If you have guns in your home, are they locked
up?
Sexual partners have been:
Yes No
Not applicable
Male Female
Is violence in your home a concern for you?
Yes No
Birth control method (circle all that apply):
Have you completed any of the following: (please check all that apply)
Advance Directive for Helathcare (ADHC)
Living Will
POLST (Physician Orders for Life Sustaining Therapy)
Page 6 of 7
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical