GRADE = BASIC INFORMATION Greeting How are you doing? How are you feeling today? I need to ask you some questions. Name What's your name? ID number What’s your ID number? Age How old are you? Date of birth What's your date of birth? When were you born? Place of birth What’s your place of birth? Where were you born? Where are you from? Occupation What's your occupation? What do you do for a living? Marital Status What's your marital status? Are you married, single, or divorced? Phone number What’s your phone number? Next of kin Who is your next of kin? Who came with you? Who is with you? Health insurance company What health insurance company do you have? * Each question is worth 1 point CURRENT MEDICAL STATUS Reason for admission What happened? What's wrong? What's the matter? Smoking intake Do you smoke? How many cigarettes do you smoke a day? How often do you smoke? Alcohol intake Do you drink alcohol? How often do you drink? How many glasses do you drink a day? Drug intake Do you use drugs? What kind of drugs do you use? Operations Have you had any major operations? Hospitalization Have you been hospitalized? Medication Are you taking any medication? What medication are you taking? Pregnancy Are you pregnant? Menstrual Period When did you get your last period? FAMILY HISTORY Does anyone in your family suffer from …. ? Diabetes Tuberculosis Allergies Cancer Triglycerides Mental Illness Heart Disease HIV / AIDS Pneumonia High Blood Pressure High Cholesterol Any other disease? Other Is there anything else I should know? When was the last time you saw a doctor?