Pulmonary and Medicine Associates

Pulmonary and Medicine Associates, PLLC

27472 Schoenherr, Suite 100

Warren MI 48088

Phone: 586-751-8844

FAMILY HISTORY - FILL IN HEALTH INFORMATION ABOUT YOUR IMMEDIATE FAMILY (Required)

Relation *

Age *

State of Health *

Age of Death

Cause of Death

RELATION	AGE	STATE OF HEALTH	AGE OF DEATH	CAUSE OF DEATH	ACTION
No family health added

SELECT ALL THAT APPLY IF YOUR BLOOD RELATIVES HAD ANY OF THE FOLLOWING (Not required)

Disease *

Relationship to you *

DISEASE	RELATIONSHIP TO YOU	ACTION
No blood relatives added

HOSPITALIZATIONS (Not required)

Year *

Hospital *

Reason for Hospitalization and Outcome *

YEAR	HOSPITAL	REASON/OUTCOME	ACTION
No hospitalizations added

OCCUPATIONAL (Required)

Current Occupation *

Check ☑ if your work exposes you to

Stress

Heavy Lifting

Hazardous substances

Other

Other work exposes

Work Related Illness/ Injury

Have you ever had a blood transfusion? *

Yes

Please give approximate dates

Dates of blood transfusion

Check ☑ which you use and how much you use

Caffeine

Frequency of caffeine use

Tobacco

Frequency of Tobacco use

Street Drugs

Frequency of street drugs use

Other

Frequency of use

Pregnancies

How Many Pregnancies?

How many children?

Complications?

To the best of my knowledge, the above information is complete and correct. I understand that it is may responsibility to inform my doctor if I, or my minor child, ever have a change in health.

Please Print name of Patient, Parent, Guardian or Personal Representative *

Relationship to Patient

Date *

Signature of Patient Parent, Guardian, or Personal Representative *

Press save, to finish your signature