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Cancer:

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Other

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Other

Drug Allergies:(required)
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Current Medications (with dosage):(required)
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Surgeries:(required)
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SOCIAL HISTORY
Do you…
Exercise Regularly (required)	Use Alcohol (required)	Use Tobacco (required)	Former Smoker (required)
Yes    No	Yes      No	Yes      No	Yes      No
If YES, how often:	If YES, how often:	If YES, how often: per day.	Date Quit

PLEASE ANSWER BELOW ONLY IF PATIENT IS A CHILD:
In Day Care? Yes No
Smokers at home? Yes No    Smoke outside?  Smoke inside?