Date of Birth: Age: Sex: M / F MEDICAL HISTORY
ADULT HISTORY FORM
Name:
Today?s Date:
Date of Birth:
Age:
Place of Birth:
Occupation:
Marital Status: Single Married Widowed Divorced
Spouse:
Spouse?s Occupation:
Chief Complaint (Reason for Visit Today):
Sex: M / F
MEDICAL HISTORY
YES
NO
Environmental Allergies
Depression
Anemia Anxiety Arthritis
Asthma
Diabetes Emphysema Gastro Esophageal Reflux Disease Glaucoma
Blood Transfusion
Heart Murmur
Cancer
HIV/AIDS
Cataracts
High Cholesterol
Congestive Heart Failure
High Blood Pressure
Clotting Disorder
Kidney Disease
COPD
Meningitis
Any additional past Medical History not listed:
YES
NO
YES
NO
Heart Attack/Coronary
Artery Disease
Nerve/Muscle Disease
Osteoporosis
Seizures
Sexually Transmitted Diseases Sickle Cell Anemia Stroke Substance Abuse Thyroid Disease Tuberculosis Ulcers
SURGICAL HISTORY
YES
NO
YES
NO
YES
NO
Appendectomy
C-Section
Joint Replacement
Brain Surgery
D&C
Prostate Surgery
Breast Surgery
Ear Surgery
Small Intestine Surgery
Coronary Artery Bypass Surgery
EGD (Upper Endoscopy)
Spine Surgery
Cholecystectomy
Eye Surgery
Tonsillectomy
Colonoscopy
Fracture Surgery
Tubal Ligation
Colon Surgery
Hernia Repair
Valve Replacement
Cosmetic Surgery
Hysterectomy
Vasectomy
Any additional Surgeries not listed:
FAMILY HISTORY Please fill in your family history with a check mark for any that apply.
Relationship AAlritvher/itiDseceased Asthma CBiartncherDefects COPD DDieapbreetsesison LSEKHHHHitiiMMMeaieerdgrgeeaslaaorhnhnncrryktitnteaiBeCaanrlyDllnrDhgoieiIgDRloosaaiLlletsegdDonetiheaessaePstsssarsraseesderbesailotsilituoryne SVOiutsibhsoetrnaLncosesAbuse
Mother Father Sister Brother Daughter Son MGM MGF PGM PGF Other
MGM=Maternal Grandmother MGF=Maternal Grandfather
PGM=Paternal Grandmother PGF=Paternal Grandfather
SOCIAL HISTORY Alcohol use: YES / NO If Yes, Drinks per Week: _______ Glasses of wine, _______ Cans/Glasses of beer
_______ Shots of liquor, _______ Drinks containing 0.5 oz. of alcohol
TESTING AND IMMUNIZATIONS
Test
Date Last Done Results (Circle)
Immunization
Year
PAP/Pelvic Exam
Normal / Abnormal Tetanus Shot
Mammogram
Normal / Abnormal Pneumonia Shot
Sigmoidoscopy Colonoscopy
Normal / Abnormal MMR (measles, mumps, rubella)
Prostate Screening (PSA)
Normal / Abnormal Hepatitis B Series
DEXA scan
Normal / Abnormal Hepatitis A Series
Polio
Flu Shot
TOBACCO USE Smoking Hx: Current smoke / Never / Former smoker Packs/day _______ Years smoked _______ Ready to Quit? YES / NO Date Quit __________
ALLERGIES TO MEDICATIONS Medication
Reaction
MEDICATIONS
Medication Name 1.
Dosage How Often
Medication Name 9.
Dosage How Often
2.
10.
3.
11.
4.
12.
5.
13.
6.
14.
7.
15.
8.
16.
Any additional medications:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
GYNECOLOGY HISTORY IF APPLICABLE Are you pregnant? How many pregnancies Children Living Miscarriages Tubal pregnancy Preterm Twins Abortions
Please indicate if you have had any experience in the last 30 days of the following symptoms:
Yes No Symptom Unusual Sweating Fatigue Fever Hot or Cold Intolerance Unexpected Weight Loss/Gain Hearing Loss, explain: Visual Disturbances Cough Shortness of Breath Chest Pain Palpitations/Racing Heart Beat Black or Bloody Stools Nausea/Vomiting Change in Bowel Movements List issues: Frequent Urination Enuresis (Excessive Nighttime Urination) Spotting or Irregular Vaginal Bleeding Genital Sore Penile discharge/Pain swelling Urinary Incontinence/Leakage Menopause Symptoms HIV Exposure Risk for Sexually Transmitted Diseases (STDs) Joint Pain/Swelling Wound Frequent Headaches Memory Loss List (bruising): Nervous/anxious Blues/sadness
Type Constitution
HENT Eyes Respiratory Cardiovascular Gastrointestinal
Genitourinary
Musculoskeletal Skin Neurological Hematological Emotional State
Other: _______________________________________________________________________________
Your doctor will review this list and let you know if a separate visit will be required to address the above symptoms.
Signature: _______________________________________________________ Date: _______________
40307 (07/17/14)
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