Yes / No    Diabetes:  Yes / No   Cancer Bowel:  Yes / No   Cancer Prostate/Breast: Yes / No   

Current Family History listed

<<Clinical Details:Family History>>

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SOCIAL HISTORY     social List - number of children - ? lives alone

or with daughter - backup support etc

Alcohol intake:

( averagenumber standard drinks - number days per week )     Smoking: ( cigs/day - when stopped )   

Current Social History listed

Smoking: <<Clinical Details:Smoking>>

Alcohol: <<Clinical Details:Alcohol>>

<<Clinical Details:Social History>>

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ALLERGIES  

Current Allergie listed

<<Clinical Details:Allergies>>

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IMMUNISATIONS

( check ADT, fluvax, pneumovax

)    

Current listed Immunisations

<<Clinical Details:Immunisation

List>>

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MEDICATIONS  -  (include

herbs, vitamins)         

Current listed medications

<<Clinical Details:Medication

List>>

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Falls in last three months: Attended

another Doctor in last six months:  Were medications prescribed:    If Yes, Details:        

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