Adult Health History Page 7

N O R T H E R N N E V A D A

HOPES

your partner in health.

SOCIAL HISTORY

Occupation (or prior occupation): _________________________________________________________

If not currently employed, please circle one:

Retired

Unemployed

Leave of absence

Disabled

Employer: ____________________________________________________________________________

Years of education or highest degree: ______________________________________________________

Marital status (please check one):

Single Partner

Married

Divorced

Widowed

Other ___________

Spouse/partner name: _____________________________________________________

Number of children: __________________

Age(s) if under 18 years: _____________________________________________________

Number of grand children: ________________

Number of great grandchildren: ________________

Who lives at home with you?

Leisure activities, group involvement, religion, volunteer work, recent travel:

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Parent category: Medical