Personal History

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Kevin Theodorou, M.D. 10585 N Tatum Blvd, D-137 Paridise Valley, AZ 85253
Patient Name*
Date*

Personal History

Do you smoke? ......... No Yes If yes, how many packs/day?
How many years did you smoke? If a former smoker, when did you quit?
Do you drink alcohol? ........... No Yes
If yes,
Have you ever felt the need to cut down on drinking? .......... No Yes
Have you ever been annoyed by criticism of your drinking? .......... No Yes
Have you ever felt guilty about your drinking? .......... No Yes
Have you ever felt the need for an eye opener? .......... No Yes

Do you drink excessive (more then 2-4 cups/day) of coffee, tea or soft drinks? No Yes
Do you exercise regularly? ..................... No Yes
Do you think you eat a healthy diet? .......... No Yes
Do you feel safe at home? .......... No Yes
Are you sexually active? .......... No Yes
If yes, is your partner? .......... male female
Do you have or have you had more than one partner? .......... No Yes
If yes, are your partners? .......... male female both
Do you use drugs for recreation (cocaine, marijuana, speed etc.)? .......... No Yes
Do you live alone? ..................... No Yes
Do have a health power of attorney? .......... No Yes
Do you use seatbelt when you drive? .......... No Yes
Do you have allergies or reactions to certain medications? .......... No Yes
If yes, list the medication and reaction

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