Alpine Medical Group Patient History Questionaire Patient History "*" indicates required fields Step 1 of 9 11% Patient Name*Date of Birth*Email PhoneLifestyleDo you feel stressed (tense, nervous, anxious or unable to sleep at night)? Not at all Only a little To some extent Rather much Very much Do you participate in social media? Yes No Do you wear a helmet when biking? Yes No Do you use a seat belt or car seat routinely? Yes No Diet and ExerciseWhat type of diet are you following? Regular Vegetarian Vegan Gluten Free Specific Carbohydrate Cardiac Diabetic Do you have any dietary restrictions? Yes No What is your exercise level? None Occasional Moderate Heavy How many times per week do you exercise? Less than 1 1-2 3-4 5-7 What types of sporting activities do you participate in? Substance AbuseDo you or have you ever smoked tobacco? Never Current Former Occasional What age did you start smoking tobacco?How much tobacco do/did you chew, vape, or smoke per day?How many years have/did you consume tobacco/vape?Do you or have you ever used any other forms of tobacco or nicotine? Yes No What was the date of your most recent tobacco screening?Has tobacco cessation counseling been provided? Yes No What is your level of alcohol consumption? None Occasional Moderate Heavy How many years have you consumed alcohol?How many times per week do you consume alcohol? Less than 1 1-2 3-4 5-7 How many days in the past year have you consumed more than 4 drinks?Have you ever been counseled for unhealthy alcohol use? Yes No Do you use any illicit or recreational drugs? Yes No Which illicit or recreational drugs have you used?Have you used IV drugs?How many years have you used illicit or recreational drugs?What is your level of caffeine consumption? None Occasional Moderate Heavy Education and OccupationWhat is the highest grade of school you have completed or degree you have received? Never attended Less than 8th grade 9th grade 10th grade 11th grade 12th, no diploma GED or equivalent High School diploma Associates: occupational, trade, or vocational program Associates: academic program Bachelor’s Master’s Professional School: MD, DDS, DVM, JD Doctoral: PhD, EdD Are you currently employed? Yes No What is your occupation?Are there any occupational health risks where you work? Yes No Advance DirectiveDo you have an advance directive? Yes No Do you have a medical power of attorney? Yes No Do you have a directive to physicians? Yes No Home and EnvironmentHave there been any changes to your family or social situation? Yes No Are you a caregiver? Yes No Do you have smoke and carbon monoxide detectors in your home? Yes No Are you passively exposed to smoke? Yes No Are there any guns present in your home? Yes No Do you use sunscreen routinely? Yes No Activities of Daily LivingAre you able to care for yourself? Yes No Are you blind or do you have difficulty seeing? Yes No Do you have difficulty hearing? Yes No Do you have difficulty concentration, remembering or making decisions? Yes No Do you have difficulty walking or climbing stairs? Yes No Do you have difficulty dressing or bathing? Yes No Do you have difficulty doing errands? Yes No Are you able to walk? Yes No Do you have transportation difficulties? Yes No Marriage and SexualityWhat is your relationship status? Unknown Married Single Divorced Separated Widowed Domestic partner Other Are you sexually active? Yes No Do you use protection during sex? Always Usually No Do you use protection against STDs? Always Usually No What type of protection is used?How many children do you have? Legacy Social HistoryAssigned sex at birth: Male Female Pronouns: He She Non-binary Other First Name used:Sexual orientation: heterosexual homosexual bisexual Other