menu 1
menu 2
menu 3
menu 4
menu 5
Social History Form 
 


Use this to enroll with Dr. Tanenbaum or to update your Social History.
 Instructions: This form asks for information about your social history and habits that will assist us in helping you.  Please be as complete as possible. Please fill out the registration form if you are a new patient.
It will require about 10 minutes to complete this form.  
This form consists of the data entry page below and a formatted results page for printing.  Try to finish all sections before browsing elsewhere or closing your browser session.  If your session is interrupted all data will be lost and you will be required to re-enter it all.  This data feature protects your privacy after you are done.
To navigate use your Browser's "Back" button to review or make change to a previous page. Use the "Format" or "Continue" buttons at the bottom of each page to move forward.  Please fill out all required* fields so we may correctly identify you.

  Patient Contact Information:
First Name*   Middle Last name*
Social Security Number xxx-yy-zzzz :*  
 Home Phone  xxx-xxx-xxxx :*

 
  Social History:
Birth Place: City:      State:  
Country of Birth:
Employer or School Name: 
Work Phone:   Occupation: 
Highest Education:  Elem High School College Post Grad
US Citizen?:  Yes  No  
Status:     Single Married  Separated Divorced Widowed 

If under the age of 18 patient lives with:   

Both Parents     Mother     Father     Guardian     Other

 

Personal Habits:

           Tobacco Use:    Alcohol Use:    

           Drug Use:           Caffeine Use:  

           Other:            
                        (Enter other significant habits we should know about.)

 

Medications and Allergies:

Select or enter Medications you are taking now and/or are allergic or sensitive to.  For multiple medicines of the same type, use "other".
Medicine Taking Name Dosage Allergic Reaction
antibiotics

  

Dose    Times/Day

opiates/codeine

  

Dose    Times/Day
diuretics/water pills

      

Dose    Times/Day
sedatives

      

Dose    Times/Day
stimulants/caffeine

      

Dose    Times/Day
Demerol

      

Dose    Times/Day
blood pressure meds

      

Dose    Times/Day
aspirin

      

Dose    Times/Day
diet pills

      

Dose    Times/Day
antacids

      

Dose    Times/Day
laxatives

      

Dose    Times/Day
cold tablets/OTC

      

Dose    Times/Day
vitamins

      

Dose    Times/Day
herbs

      

Dose    Times/Day
Other

      

Dose    Times/Day
Other

      

Dose    Times/Day

Terms and Conditions:
I agree that I am solely responsible for the security, content, dissemination by any means and any other use of the information created by using this electronic form.  Further, I hold Dr. Tanenbaum harmless for any or all consequences resulting from the dissemination of this information by means not under his care and control.

I have read and reviewed this form thoroughly.  I accept the above Terms and Conditions and represent that the information provided is accurate and complete to the best of my knowledge.*  Acknowledge by entering your full name below.
Signature of Patient / Legal Guardian:

Check Results and Print:
Click on "Format" to review and print your completed form.  If you need to make changes use your browser's "Back" button to return here.
The "Reset" button clears all form data.  All information will be lost.