FIRST NAME MI  LAST NAME

TITLE / NICKNAME

AGE DATE OF BIRTH BIRTH PLACE

WHO IS YOUR MEDICAL DOCTOR?

LIVING INDEPENDENTLY? yes no

PRESENT OCCUPATION

OCCUPATIONAL DUTIES

HOBBIES AND INTERESTS

ALLERGIES

DO YOU USE TOBACCO PRODUCTS? YES NO

DO YOU DRINK ALCOHOLIC?

DO YOU DRINK CAFFEINATED BEVERAGES?

LIST ALL CURRENT MEDICATIONS                                                             SURGERY HISTORY Include laser eye surgeries.