NWSPM Patient Questionnaire

Today's Date*

Date

Name*

First NameLast Name

Date of Birth*

Date

Marital Status*

Children - Total number*

Dependents (children, other family members) living in the home*

Do you exercise (for at least 20-30 minutes)?*

Do you use tobacco?*

Are you interested in help to stop using tobacco?*

YesNo

Do you drink alcohol?*

Please check all that you are CURRENTLY using (within the last month):*

Please check all that you have used within the last YEAR:*

Do you drink caffeinated beverages?*

Which caffeinated beverages do you drink regularly?*

Are you currently in school?*

When was the last time you were in school (year)?*

What is the highest level of schooling you have finished?*

Are you currently employed?*

When was the last time you worked if not currently working (year)?*

What has been your primary occupation? What sort of work have you done?*

Have you ever served in the military?*

Which branch of the military did you serve under?

What years did you serve (year to year)?

Did you ever experience combat while serving?

Were you injured during your time of service?

Do you receive disability benefits from your time of service?

Please list all surgeries you have had (surgery type, year):