Illnesses: c Asthma c Heart attack

c Back Pain c Heart murmur

c Cancer c High blood pressure

c Clot in lungs c High cholesterol

c Diabetes ( Type ) X ____ yrs c High triglyceride

c Emphysema c Rheumatic fever

c Gout c Tuberculosis

c Others:


Surgeries: c Appendectomy c Hemorrhoidectomy

c Back surgery c Hysterectomy

c Cholecystectomy c Pacemaker

c CABG c Tonsilectomy

c Cataract c Others


Medications Currently taken: c None c See the list of meds (medications)


Drug Allergies: c None c Penicillin causing __________ c Others:_________________________________





c CAD before age 55 (Male)/45 (Female)

c Cancer c High blood pressure

c Diabetes c High cholesterol

c Gout c High triglyceride

c Others:




Marital Status: c Single c Married X _____ years c Remarried

c Separated c Divorced c Widow

c Others: c Name of spouse/significant __________ c Living in ___________


Children: c Daughter(s) ____ c Son(s) ____ c None


Smoking: c Never smoked c Used to smoke c Has cut down to _________ c Smokes

c Packs/numbers of cigarettes/day _____ c Cigars/day _____ c Pipes/day ____

c Years of smoking ____ c Stopped smoking in year _________


Alcohol: c Does not drink c Used to drink c Has cut down to _____________ c Drinks

c Cans of beer ____ /_____ c Glasses (Ounces) of wine ____ /_____ c Shots of liquor ____ /_____

c Years of drinking ______ c Stopped drinking in year ________


Coffee: c None c Occasionally c ______ Cups/day


Drugs: c None c Marijuana/Others ____________________________________________ for ____ years


Occupation(s): Job description ____________________________________________________________________


Work Status: c Employed c Unemployed c Self-employed c Retired c Disabled because of __________


Education: c Grade ______ c High School ________________ c College Yrs/Degree ______________ c None


Regular Exercise: c None c Walking ___________________ c Others:_______________________________


Do you have an advanvce directive: c Yes c No