Personal History

When last did you have a Physical?

What was the last time you had a colonoscopy and/or a fit test?

When was the last time you had a DEXA scan (Bone Density Exam)?

When was the lasst time you had a Mammogram?

When was the last time you had a Papanicolaou Test(Pap Smear)?

Have you traveled out of the country Recently?

Do you know or have ever used IV drugs?

Do you or have ever abused prescription drugs?

Do you or have you evr used street drugs (cocaine, marijuana,etc)?

Are you currently sexually active?

Do you practice safe sex?

Have you ever had gay sex?

Do you have any screws or plates in your body?

Do you suffer from claustrophobia?

Are you currently Pregnant?

Do you smoke?

If yes how many cigarettes a day?

Do you drink Alcohol?

If yes how much and how often?

Have you ever been involved in a vehicle accident?

Do you wear seatbelt 90% of the time?

Do you exercise regulary?

Do you have a durable power of attorney?

Do you have a living will?

Do you want to sign a durable power of Attorney?

Do you wish to sign a living will,which will become part of your chart?

Signature of Patient or Resp.Party

Date

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