Identification

Technical Specifications for the "Enrollment" Module

Basic Info
First Middle Last DOB / / (m/d/y) select SSN
Contact Info Address1 Address2 City State Zip Phone

Emergency Contact

Name
Phone
Relationship

Demographics
Gender Male   Female Ethnicity Hispanic

African-AmericanAsian-AmericanCaucasianNative AmericanOther Primary Language EnglishSpanishFrenchChineseJapaneseVietnamesseOther

Level of Education Elementary

Junior HighHigh SchoolBachelorMA/PhDOther Homeless Check for Yes Marital Status SingleMarriedSeparatedDivorcedWidowed

Monthly Income

Number of Kids

Kids at Home

Adults at Home

Documentation Check for Yes

Assets Check for Yes

Family History
Mother Cause of Death Mother Age of Death
Father Cause of Death Father Age of Death
Mother Father Siblings   Mother Father Siblings High Cholesterol (HL) Allergies High Blood Pressure-HT Breast Cancer Heart Attack Other Cancer Coronary Artery Disease Depression Stroke Schizophrenia Diabetes Alcoholism Thyroid Clotting Disorder Asthma Sickle Cell Anemia

Medical History
Current Medications Drug Prescription Start (mm/dd/yy) End (mm/dd/yy) Add Allergies To be listed

Add

Hospitalizations Title Description Start (mm/dd/yy) End (mm/dd/yy) Add

Surgeries Procedure Description Date (mm/dd/yy) Add

Diseases

Childhood Diseases Measles Mumps Rubella Whooping Cough Rheumatic Fever Scarlet Polio Cancers Colon Cancer Living Cancer Lung Cancer Melanoma Other Skin Cancer Breast Cancer Endocrine Hyperthyroid Hypothyroid Diabetes High Cholesterol

Hematological Thalesseima Anemia Clotting Disorder Psych/Substance Abuse Schizophrenia Bipolar Anxiety Disorder Alcoholism Drug Dependence Infections HIV and/or AIDS Chicken Pox Hepatitis A Hepatitis B Hepatitis C Syphilis Gonorrhea Chlamydia Tuberculosis

Neurological Parkinson Disease Seizure Migraine Ophthalmologic Diabetic Retinopathy Glaucoma Cataracts Cardio/Neuro Vascular Hypertension Emphysema Angina Heart Failure Stroke (CVD) Peripheral Vascular Disease Respiratory Emphysema Asthma GI GERD Cirrhosis

GU/Renal Renal Failure Benign Prostatic Hypertrophy Immunological Lupus/SL Arthritic Osteoarthritis Other Illnesses Comments

Social History
Past Current Never Marijuana Methamphetamine Cocaine Heroin Designer Drugs/OTC Med IV Drug Use Tobacco Alcohol Sexually Active Check for Yes Sexual Preference Men   Women   Both Lifetime Sexual Partners     Contraception   Condoms Spermicide BC Pill Vasectomy/Tubal Intrauterine Device None Diaphragm
Tobacco Packs Per Day Years of Smoking Alcohol Drinks Per Day Domestic Violence Past   Current   Never