History

GILLESPIE COUNTY UROLOGY

Patient Name:

DOB:

Social History:

History of Tobacco Use:

Current Smoker Former Smoker Never Smoked

Frequency/Amount:

History of Alcohol Use:

Daily Occasional Former Never

Frequency/Amount:

Family Medical History:

Alive:

Father

Mother

Brother

Sister

Father Cause of Death:

Mother Cause of Death:

Brother Cause of Death:

Sister Cause of Death:

COPD:

Father

Mother

Brother

Sister

CVA/TIA:

Father

Mother

Brother

Sister

Diabetes:

Father

Mother

Brother

Sister

Hypertension:

Father

Mother

Brother

Sister

Kidney Disease:

Father

Mother

Brother

Sister

Liver Disease:

Father

Mother

Brother

Sister

Myocardial Infarction:

Father

Mother

Brother

Sister

Prostate Cancer:

Father

Mother

Brother

Sister

Colon Cancer:

Father

Mother

Brother

Sister

Ovarian Cancer:

Father

Mother

Brother

Sister

Stones:

Father

Mother

Brother

Sister

Heart Disease:

Father

Mother

Brother

Sister

Breast Cancer:

Father

Mother

Brother

Sister

Bladder Cancer:

Father

Mother

Brother

Sister

Kidney Cancer:

Father

Mother

Brother

Sister

Other:

Other:

Other:

Other:

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