Family Medical History Patient Name Email Address Date of Birth SSN Please list all surgeries and year: Please list current medications: Are you allergic to any medications? If yes, please list: Are there any family members with medical problems? If so, who and what kind of problems? Please list below: Mother Living or Deceased —Please choose an option—LivingDeceased Father Living or Deceased —Please choose an option—LivingDeceased Maternal Grandmother Living or Deceased —Please choose an option—LivingDeceased Maternal Grandfather Living or Deceased —Please choose an option—LivingDeceased Paternal Grandmother Living or Deceased —Please choose an option—LivingDeceased Paternal Grandfather Living or Deceased —Please choose an option—LivingDeceased Brother Living or Deceased —Please choose an option—LivingDeceased Sister Living or Deceased —Please choose an option—LivingDeceased Do you smoke? If Yes, how much? If Yes, how long? Have you ever smoked? Do you use E-cig? Do you Vap? Do you chew or dip tobacco products? Do you drink? If Yes, how much? Do you use eleicit drugs? If yes, what kind?
