Main reason(s) for your visit today? ADULT HEALTH HISTORY Do

Name:_
ADULT
HEALTH HISTORY
Date of Birth:
/_
/
 Female  Male Language:
Main reason(s) for your visit today?
Please list all medications you are currently taking and the
dosage. Include vitamins and supplements.
Medication
Dose
Do you have any allergies to the following?
None
Aspirin
Codeine
Latex
Penicillin
Sulfa Drugs
Other Antibiotics
Food Allergies
Morphine
Pet or Seasonal Allergies
Other:
Please note reactions:
Please indicate if your or a member of your family have ever had any of the following conditions. Note which relative.
Yourself
Alcohol/Drug Abuse
Alzheimers
Anemia
Arthritis
Asthma
Bleeding Disorder
Blood Clots
Cancer, Breast
Cancer, Colon
Cancer, Skin
Cancer, Other
Cancer, Prostate
Colon Polyp
Coronary Artery Disease
Depression
Diabetes (childhood)
Diabetes (adult)
Emphysema
Epilepsy / Seizures
Glaucoma
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Family
Member
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Which
relative?
Yourself
GERD
Gynecological Condition
Heart Attack
Hepatitis A / B / C
High Blood Pressure
High Cholesterol
Irritable Bowel Synd.
Kidney Disease
Liver Disease
Mental Health Cond.
Migraine Headaches
Osteoporosis
Prostate Conditions
STDs
Skin Condition
Sleep Apnea
Stomach Ulcer
Stroke
Thyroid Condition
Urinary Problems
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Family
Member
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Which
relative?
Please list any past surgeries, hospital visits, or serious injuries, and the date when, and location where they occurred.
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Women’s Health History
If applicable, please list the most recent date and results.
Age at first menstrual period:
Date of start of last menstrual period:
Are you menopausal?
N
Have you had a hysterectomy?
Number of Pregnancies :
N
Children:
Colonoscopy
_/
/
Result:
Dexa Scan
_/
/
Result:
/
/
Result:
TB Test
Type of birth control:
Tetanus Shot
of last breast exam
of last Pap smear
Do you regularly perform breast self-exams?
N
/
Influenza Vaccine
/
/
Pneumonia Vaccine
/
/
For Men: Date of last prostate exam
Do you have an Advanced Directive or a Living Will?
/
Y
_/
_/
N
Are you currently under the care of any specialists (cardiologist, rheumatologist, OB/GYN, etc.)?
If yes, please provide contact information:
Doctor name:
Doctor name:
Specialty:
Specialty:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone:
Phone:
Y
N
Other Health Issues
□ Yes □ No □ Never
Tobacco Use: Have you ever smoked?
(If you never smoked, please go to alcohol use question.)
Quit date:
Exercise: Do you exercise regularly? □ Yes □ No
What kind of exercise?
How many years did you smoke?
Approximately how many packs a day did you smoke?
Current smoker: Packs/day:
# of years:
Other tobacco: □ Pipe □ Cigar □ Snuff □ Chew
Have you ever used needles to inject drugs? □ Yes □ No
SOCIAL HISTORY:
Would you like help to quit? □ Yes □ No
Alcohol Use: Do you drink alcohol? □ Yes □ No
# of drinks/week:
□ Beer □ Wine □ Liquor
Drug Use: Do you use marijuana or recreational drugs? □ Yes □ No
Do you have a history of marijuana or drug use? □ Yes □ No
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How long (minutes)?
How often?
Diet: How would you rate your diet? □ Good □ Fair □ Poor Would
you like advice on your diet? □ No □ Yes
Do you have special dietary needs? □ Yes □ No If “yes,” please
Occupation (or prior occupation):
Employer:
describe:
Safety: Do you use a bike helmet? □ No bike □ Yes □ No
Do you use seatbelts consistently? □ Yes □ No
Does your home have a working smoke detector? □ Yes □ No
Is violence at home a concern for you? □ Yes □ No
retired/unemployed/leave of absence/disabled (circle one)
Years of education or highest degree:
Marital status (circle one): single, partner, married, divorced, widowed, other:
Who lives at home with you?
Provider Signature: _______________________
Date:
__________________
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