Number of lifetime sexual partners:____
Gender(s) of sexual partners: (  ) Male (  ) Female (  ) Both
Practice safe sex? (  ) Yes  (  ) No

WORK HISTORY:

Are you currently employed:  (  ) Yes  (  )  No

Type of work performed (describe) ____________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

Hours worked per day________, per week ____

Describe any difficulties experiencing in performing work:

Have you every been evaluated by a Occupational Therapist?

 (  ) Yes  (  ) No

If yes, when:______________________________________

Name and contact of therapist:

    Name_______________________

    Phone Number________________

PREVENTATIVE  HEALTH  HISTORY

TOBACCO:

Have you ever used tobacco products? (  ) Yes (  ) No
No. of cigarettes smoked per day: ____
No. of cigars smoked per day: ____
No. of years smoked: ____
Have you ever quit? (  ) Yes (  ) No

ALCOHOL (beer, liquor, wine)

No. of drinks _____ per day _____ per week
Have you ever quit?

(  )  Yes   (  ) No
Have you abused alcohol?

(  )  Yes   (  ) No

Has your job performance ever been affected by alcohol:

(  )  Yes   (  ) No

Has your marriage/relationship every been affected:

(  )  Yes   (  ) No

Family or social relationships affected by alcohol:

(  )  Yes   (  ) No

Have you every experienced a blackout:

(  )  Yes   (  ) No

If yes, how often ______________________

DRUGS
(marijuana, cocaine, amphetamines, heroin, etc)

Have you ever used drugs? (  ) Yes (  ) No
Which drug(s) have you used? ____________________________
When was your last use? ________________________________

EXERCISE

Do you regularly exercise? (  ) Yes  (  ) No
If yes, what type of exercise(s) (describe)?

__________________________________

__________________________________

__________________________________

How often do you exercise per week? _______
Length of exercise sessions: _________

Have you been assessed by a Physical Therapist: (  ) Yes (  ) No

If yes:

    Name:___________________

    Phone:___________________

Are you currently seeing this therapist?  _____

When was your last appointment? __________

SAFETY

Check items that are applicable to you:

Unsteady Gait: (  ) Yes (  ) No

Difficulty Walking: (  ) Yes (  ) No

Falls: (  ) Yes (  ) No

Frequency: ____________________

Dizziness: (  ) Yes (  ) No

Frequency: ____________________

Drives: (  ) Yes (  ) No

Frequency: ____________________

Normal Distance:  ______________

Seat-belt use: (  ) Yes (  ) No

Smoke alarm in home? (  ) Yes (  ) No

Gun: (ownership, loaded, locked)

Do you keep a gun in the home? (  ) Yes (  ) No

If yes, is it locked? (  ) Yes (  ) No
If yes, is it loaded? (  ) Yes (  ) No

DIET

Difficulty Swallowing: (  ) Yes (  ) No

If yes, extent (identify liquids, type of food, etc.):

______________________________________

______________________________________

______________________________________

Speech/Swallowing Therapy Assessed: (  ) Yes (  ) No

Clinical Dietician Assessment Performed: (  ) Yes (  ) No

Number of meals each day: ____

Average length of each meal: ____
Glasses of water per day: ____

No. of snacks per day: ____
No. of servings of fruits per day: ____
No. of servings of vegetables per day: ____

No. of servings of meat per day: ____
No. of servings of dairy products per day: ____

Average Calory Consumption per day:____

FAMILY HISTORY

(consider neurological disease, heart disease, diabetes, cancer)

Father Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Mother Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Spouse Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Brother(s) Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Sister(s) Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Paternal-Grandfather Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Paternal-Grandmother Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Maternal-Grandfather Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Maternal-Grandmother Living (  ) Yes (  ) No Age Age at death ____
Medical conditions and/or cause of death _____________________________

Identifiy any Uncles and Aunts with medical conditions/identify condition:

HOBBIES:   

Describe what activities you like to do in your free time: