1 |
Seatbelt |
Primary Language Spoken: English |
SH Other |
Language |
Do you/your family use safety helmets? |
Abuse |
Abuse: Current or Past (Physical, Sexual, or Emotional) |
Helmets |
Seatbelts used. |
2 |
Location Names |
NAME lives with her parents and sister in PLACE. |
Residence |
House |
Environmental History: The family lives in a 6 year old home in a rural setting. |
Apartment |
Lives with parents and half sister in the upstairs of a house while grandmother and a few cousins live on the first floor of a house. |
3 |
Smoke exposure |
NO: Lead, smokers at home, radon, pool/spa, known TB exposure. |
Living Situation Exposure |
Safe |
Do you feel safe in your home: Yes/No |
Guns |
No guns at home. |
4 |
Parents |
Lives at home with mother, grandmother, aunt and 2 older half-siblings. |
Family |
Brother |
Lives with biological mother and maternal half sister. |
Sister |
5 |
Relationship |
Parent Relationship: Married |
Marital Status |
Married |
Divorced-almost. |
Single |
Lives with husband and 2 dogs. |
6 |
Work |
Patient did some part time work as a cashier for COMPANY in the past. |
Occupation |
Part-time/Full-time |
Mom is a homemaker. |
Company Names |
Father is an engineer at COMPANY. |
7 |
Lives with |
Lives in PLACE with S.O. NAME and son, NAME. |
Living Situation |
Boyfriend/Significant |
NAME lives at home with his mother. |
Other (S.O.) Siblings/Parents |
Lives with her husband and 3 healthy children. |
8 |
Calcium |
Calcium intake: eats cheese and drinks a lot of milk. |
Diet |
Diet |
Age solids introduced – 4 months, table food. |
Food |
Balanced diet: Yes |
9 |
Alcohol |
Alcohol use is < 1 alcoholic drinks per week |
Alcohol Use |
Socially |
Describes intermittent problems with alcohol in terms of excessive drinking in the past. |
Drinks |
Alcohol use is rare. |
10 |
Cigarettes |
They live in a house with no smoke exposure. |
Tobacco Use |
Smoking |
Grandmother smokes outside. |
Exposure |
The patient has 20 yr hx of intermittent pipe and cigar use. |