|
Mode of Contact
|
OK to leave a voice message.
|
|
OK to send text notifications
|
Reason for your visit to A-to-Zen
|
|
How did you hear about A-to-Zen?
• • •
|
If referral, whom may we thank for the referral?
|
|
SOCIAL HISTORY
|
Age/Children
/
|
|
Occupation
|
Race
|
|
Ethnicity
|
Language(s)
|
|
Highest level of education
|
|
|
Do you consume Alcohol
|
If yes, No.of.Times / Week
/
|
|
Do you use Cannabis
|
If yes, No.of.Times / Week
/
|
|
Do you use Caffeine?
|
If yes, No.of.Times / Week
/
|
|
Do you smoke Tobacco
|
If yes, No.of.Times / Week
/
|
|
Others
|
If others, Please mention.
|
|
Prior Surgeries.
|
If yes, please mention.
|
|
Any other hospitalizations
|
If yes, please mention.
|
|
Chronic illnesses/conditions, current or past:
• • •
|
If others, please mention.
|
|
List Current Medications and mention the dosage
|
List non-prescription medications & supplements:
|
|
Allergies to medications
|
If yes, please mention
|
|
Other Allergies
|
If yes, please mention
|
|
Women Only
|
|
|
Total number of pregnancies
|
Total number of live births at full term:
|
|
Total number of pre-term live births
|
Total number of living children
|
|
Currently practicing Birth-control
|
|
|
Family History
|
|
|
Family members with chronic medical condition
|
If yes, please mention the relation
|
