Norcal Health Care, Inc.

Name

Telephone NUmber

Check all that apply to you or your immediate family (parents, siblings, grandparents)

Asthma / Lung Problems Cancer Cardiac Disease Diabetes History of Back Pain Hypertension Psychiatric Disorders Seizure Disorder Stroke

Check all symptoms you are currently experiencing

Allergy Cardiovascular Chest Pain Connective Tissue Disease Diabetes Mellitus Eating Disorder Ear / Nose / Throat Eye Fever Gastrointestinal Genitourinary Hemtalogical Lymphatic Musculoskeletal Pain Neurological Psychiatric Respiratory Skin Weight Gain Weight Loss

If you are a woman, are you currently pregnant, or is there a possibility that you are pregnant?

Are you currently using or do you have a history of tobacco use?

Yes No

Are you currently using or do you have a history of illegal drug use?

Yes No

Do you feel you are at risk for falls or falling injuries?

Yes No

Please describe your alcohol consumption :

Daily Weekly Monthly Occasionally Rarely Never

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