Includes but not limited to occupation and major hobbies family status tobacco

Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Occupation : Works at a civil engineering firm Family: Married (wife Maria) with two children (boy-Sam 26yo and girl-Allie 19yo) – reports no stress at home Hobbies/Exercise: Enjoys riding his bike for exercise but has not been able to do so recently because his bike was stolen Diet and Nutrition :  Food intake: o Breakfast: usually a granola bar and instant breakfast, occasional big breakfast on weekends) o Lunch: sub sandwich o Dinner: grilled meats Substance Use :  Illicit drugs: Reports usage of marijuana when “Carter was in office.” Denies any current illicit drug use. Last used over 30 yrs ago  Alcohol: Drinks no more than 2-3 alcoholic drinks in one sitting. Drinks no more than 2-3 alcoholic beverages in a week and only drinks on

the weekends.  Denies tobacco usage Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Mother’s Health:  Diabetes Type 2  Hypertension  Living age 80 Father’s Health  Hypertension  Hyperlipidemia  Obese  Deceased – Colon Cancer age 75 yrs Brother  Deceased – age 24 in a motor vehicle accident Sister  Diabetes Type 2  Hypertension  Living age 52 yrs Paternal Grandfather’s Health  Deceased – old age 85 yrs Paternal Grandmother’s Health  Deceased – pneumonia 78 yrs Maternal Grandfather’s Health  Deceased – Heart Attack 54 yrs Maternal Grandmother’s Health  Deceased – breast cancer 65 yrs of age Son  Healthy  26 yrs old Daughter  Asthma  19 yrs old

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional If patient denies all symptoms for this system, check here: ☐ Skin If patient denies all symptoms for this system, check here: ☒ HEENT If patient denies all symptoms for this system, check here: ☒ ☐ Fatigue Denies ☐ Weakness Denies ☐ Fever/Chills Denies ☒ Weight Gain 20lbs over last couple of years ☐ Weight Loss Denies ☐ Trouble Sleeping Denies ☐ Night Sweats Denies ☐ Other: Click or tap here to enter text. ☐ Itching Click or tap here to enter text. ☐ Rashes Click or tap here to enter text. ☐ Nail Changes Click or tap here to enter text. ☐ Skin Color Changes Click or tap here to enter text. ☐ Other: Click or tap here to enter text. ☐ Diplopia Click or tap here to enter text. ☐ Eye Pain Click or tap here to enter text. ☐ Eye redness Click or tap here to enter text.