Medicare History

MEDICAL HISTORY:
Illnesses:  ***
Hospitalizations:  ***
Surgeries:  ***
Injuries:  ***
Patient is able to perform all activities of daily living with the EXCEPTION of: ***none/eating/feeding/bathing/dressing/toileting/transferring/maintaining continence***.
Falls in the last year:  ***No/Yes ---details---***
SOCIAL HISTORY:
Alcohol use: ***none/drinks --- every ---***
Tobacco use: ***none/smokes --- every ---***
Illicit drug use: ***none/uses ---***
Diet includes: ***vegetables/fruits/dairy/meat***
Physical activity includes: ***
FAMILY HISTORY:
Hereditary diseases:  ***
Conditions that place the patient at increased risk for disease:  ***
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:  
This is an online version of a template by Stephen P. Merry, MD, MPH, Consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota[/conditional]