PCCS/NSDCPatient History QuestionnaireBack to all Forms Patient Name Date of Birth MM slash DD slash YYYY Today'sDate MM slash DD slash YYYY Past Surgical HistoryType of Surgery Date Type of Surgery Date Type of Surgery Date Type of Surgery Date Type of Surgery Date Past Medical HistoryPlease check any of the following health problems with which you have been diagnosed Alcoholism Anemia Arthritis Asthma Bleeding Disorder Blood Clots Cancer Cataracts Chemical Dependency Coronary Artery Disease Depression Diabetes Emphysema/COPD Epilepsy/Seizures Gastric Reflux Disease Glaucoma Gout Hepatitis HIV/AIDS High Cholesterol Hypertension Irregular Heartbeat Kidney Stones Migraine Headaches Osteoporosis Pacemaker Pneumonia Prostate Problems Shingles Stroke Suicide Attempt Thyroild Disease Tuberculosis Vascular Disease History of Pain Injury What type of cancer? Other health problems Family HistoryAre there any diseases that run in your family: Yes No If yes, please list below:Maternal Paternal Maternal Paternal Maternal Paternal Diseases of IMMEDIATE FAMILY members? Yes No If yes, please list below:Disease Select all that apply Mother Father Brother Sister Son Daughter Disease Select all that apply Mother Father Brother Sister Son Daughter Disease Select all that apply Mother Father Brother Sister Son Daughter Father Alive Deceased Medical Problems Mother Alive Deceased Medical Problems Children Alive Deceased Medical Problems Maternal Grandmother Alive Deceased Medical Problems Maternal Grandfather Alive Deceased Medical Problems Paternal Grandmother Alive Deceased Medical Problems Paternal Grandfather Alive Deceased Medical Problems Comments Social HistoryLiving arrangement Apart/Condo House Military Trailer ECF Other Describe other living arrangement Marital Status Married Single Widowed Number of Children (Live Births)? Number of Adults living in household? Number of Children living in household? Education GED Grade School High School Graduate Collage Graduate Post-Graduate Employment Currently employed Currently unemployed Retired Student If employed, are you: Full-time Part-time Military Active Air Force Army Marines Navy Reserve Retired Travel Africa Asia Europe Middle East Out of Country Out of State Date traveled to Africa Date traveled to Asia Date traveled to Middle East Date traveled to Europe Date traveled out of the country Date traveled out of the State Pets Birds Cats Dogs Other What kind of "Other" pet? Tobacco HistoryDo you smoke cigarettes daily? Yes No #Packs per day? #Years? Do you smoke cigarettes some days? Yes No When? Lifetime NON-Smoker? Yes No CIGAR/PIPE Smoke? Yes No Frequency? Currently use SMOKELESS Tobacco? Yes No Frequency? Quit Smoking LESS THAN 10 years ago? Yes No Quit Smoking LESS THAN 5 years ago? Yes No Quit Smoking MORE THAN 10 years ago? Yes No Alcohol HistoryDo you drink alcohol currently? Yes No How many Years? Frequency 1-2 drinks/day More than 2 drinks/day 1-4 drinks/wk 7 drinks/wk 10 drinks/wk 14 drinks/wk Rarely Do you drink socially? Yes No When? Never drink alcohol? Yes No Quit drinking this year? Yes No If NO, When? Substance HistoryHave you used non-prescribed or illegal drugs? Yes No What kind? Number of Years Abusing? 1 2 3 5 10 15 20 30+ Have you smoked Marijuana? Yes No When? How Long? Have you used Cocaine? Yes No When? How Long? AllergiesDRUG Allergies No Yes List the Drugs you are allergic to AND reactions:Current Medications(PLEASE REFER TO YOUR PRESCRIPTION LABELS IF AVAILABLE) PLEASE FILL OUT COMPLETELY AND ACCURATELYMedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add Remove-MedicationDose (mg)How oftenHow many times per day Add RemoveFOOD AllergiesDo you have any known food allergies Yes No Check if Allergic to the following AND state reaction Baker's yeast Dyes Gluten Peanuts Strawberries Wheat Chocolate Milk Eggs Shellfish Tomatoes Baker's yeast RXN Dyes RXN Gluten RXN Peanuts RXN Strawberries RXN Wheat RXN Chocolate RXN Eggs RXN Milk RXN Shellfish RXN Tomatoes RXN Occupational HistoryPlease select IF EXPOSURE TO the followingInorganic Dusts Cement Fire Fighter Plumbing Quarries Sandblasting Shipyard Work Stone Carving Welding Organic Dusts Building Inspection Farming Handling vegetable matter or animals Noxious Fumes Auto body work Manufacturing plastic Spray painting Working with dyes or glues Hot Tub/Jacuzzi Yes No Chemicals or Fires Yes No High Pressure Washing Yes No EPWORTH SLEEPINESS SCALEHow likely are you to doze off or fall asleep in the following situations? Even If you have not done some of these things recently try to estimate the effect it might have on your level of drowsiness. Use the following scale to choose the most appropriate number for each situations.0 = would NEVER doze 1 = SLIGHT chance of dozing 2 = MODERATE change of dozing 3 = HIGH change of dozingSitting and reading1234Watching TV1234Sitting, inactive in a public place (in a meeting or watching a movie)1234As a passenger in a car for an hour without a break1234Lying down to rest in the afternoon when circumstances permit1234Sitting and talking to someone1234Sitting quietly after lunch without alcohol1234In a car, while stopped for a few minutes in the traffic1234Have you been told or do you have any of the following?Talk while asleepYesTime/Wk.Age of onsetLast occurred Add RemoveWalk while asleepYesTime/Wk.Age of onsetLast occurred Add RemoveGrit teeth while asleepYesTime/Wk.Age of onsetLast occurred Add RemoveWake up screaming or afraid for no reasonYesTime/Wk.Age of onsetLast occurred Add RemoveStop breathing in your sleepYesTime/Wk.Age of onsetLast occurred Add RemoveAwaken with heartburn or sour tasteYesTime/Wk.Age of onsetLast occurred Add RemoveOther -YesTime/Wk.Age of onsetLast occurred Add RemoveDoes anyone in your family have any sleep problems? Yes No If yes, briefly describe and give their relationship to you:
