Name ______________________________ DOB ______________________ Chart # __________________

Allergies ____________________________________________________________________________________________________________

Occupation _______________________________________________________________________________________________________

Assess the patient for the following personal risk factors:

1. Coronary heart disease:
   1. High-fat/high-cholesterol diet
   2. Obesity
   3. Elevated cholesterol level
   4. Stroke
   5. Hypertension
   6. Tobacco use
2. Lung cancer:
   1. High-fat/high-cholesterol diet
   2. Tobacco use
3. Cervical cancer:
   1. Early age of first intercourse
   2. Multiple sexual partners
   3. History of HPV
4. Breast cancer:
   1. Nulliparous
   2. Primigravida after age 35
   3. High-fat diet
5. Colon cancer:
   1. History of polyps
   2. High-fat diet
6. Osteoporosis:
   1. Less than 1 g of calcium per day
   2. History of tobacco or alcohol use
   3. Sedentary lifestyle
   4. Thin, Caucasian
   5. Female gender
7. Glaucoma/visual impairment:
   1. Family history of glaucoma
   2. Diabetes mellitus
8. STIs/HIV:
   1. Alcohol and drug use or abuse
   2. Multiple sexual partners
   3. Homosexual or bisexual partner
   4. History of intravenous drug use/needle sharing
   5. History of blood transfusion
   6. Exposed to or past history of STI
   7. Exchanging sex for drugs or money
9. Substance abuse:
   1. Alcohol or drug use history including “street drugs” and opioids
   2. Family history of substance abuse
   3. Stress or poor coping mechanisms
   4. Administer the CAGE Assessment:
      Have you ever tried to Cut down on your alcohol/drug use?
      Do you get Annoyed if someone mentions your use is a problem?
      Do you ever feel Guilty about your use?
      Do you ever have an Eye-opener first thing in the morning after you have been drinking or using the night before?
10. Accidents and suicide:
    1. Previous suicide attempt
    2. Family history of suicide
    3. Alcohol use
    4. Substance use
    5. History of depression
    6. High-stress or “hot-reactor” personality
    7. Male gender
    8. Poor coping mechanisms or stress
11. Safety:
    1. Does not use seat belt or car seat
    2. Drinks and drives
    3. Drives over the speed limit
    4. Does not wear safety helmet if driving motorcycle
    5. Inadequate number of smoke detectors or none in the home

CAD, coronary artery disease; DM, diabetes mellitus; HPV, human papilloma virus; STI, sexually transmitted infection.