Please complete all 5 pages Name Your answers on this form will

Adult Medical History Form
____________________________
Please complete all 5 pages
Name
Your answers on this form will help your clinicians understand your medical concerns and conditions
better. If you are uncomfortable with any question, do answer it. Best estimates are fine if you cannot
remember specific details. Thank you!
PRESENT HEALTH CONCERNS: _________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control
pills, herbs:
Medication
Dose
Times
per day
Medication
Dose
Times
per day
ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS:
Medication
Reaction or Side Effect
PERSONAL MEDICAL HISTORY:
Do you have now (current) or have you had (past) any of the following conditions?
Condition
Alcohol / Drug abuse
Allergy (Hay Fever)
Anemia
Anxiety
Arthritis (Rheumatoid)
Arthritis (Osteoarthritis)
Asthma
Bladder / Kidney Problems
Blood Clot (leg)
Blood Clot (lung)
Cancer Breast
Cancer Colon
Cancer Other Type
Colon Polyp
Coronary Artery Disease
Depression
Diabetes (adult onset)
Diabetes (childhood onset)
Diverticulosis
Emphysema
Gallbladder Disease
Gastroesophageal Reflux (Heartburn/GERD)
Code
305.00/305.90
477.9
285.9
300.00
714.0
715.90
493.9
453.40
415.11
174.9
153.9
211.3
414.00
311
250.00
250.01
562.10
492.8
574.20
530.81
Current
Past
☐NONE
Comments
PERSONAL MEDICAL HISTORY Continued:
Condition
Glaucoma
Gout
Gynecological Conditions (Endometriosis)
Gynecological Conditions (Fibroids)
Heart Attack
Hepatitis – Type A
Hepatitis – Type B
Hepatitis – Type C
Hepatitis – Other
High Blood Pressure
High Cholesterol
Hip Fracture
Irritable Bowel Syndrome
Kidney Disease / Failure
Kidney Stones
Liver Disease
Migraine Headaches
Osteoporosis
Pneumonia
Prostate (enlargement)
Seizure / Epilepsy
Skin Condition (Eczema)
Skin Condition (Psoriasis)
Skin Condition (Abnormal Moles)
Sleep Apnea
Stomach Ulcer
Stroke
Thyroid High (Overactive) / Hyperthyroidism
Thyroid Low (Underactive ) / Hypothyroidism
Other (list)
Other (list)
Code
365.9
274.9
617.9
218.9
410.90
070.1
070.30
070.51
070.59
401.9
272.0
820.8
564.1
586
592.0
573.9
346.90
733.00
486
600.00
780.39
692.9
696.1
238.2
780.57
531.9
434.91
242.90
244.9
Current
Past
Comments
SURGICAL HISTORY (Please list all prior operations and dates):
Operation
Date
Operation
Date
WOMEN’S GYNECOLOGIC HISTORY:
For Women: # pregnancies: ____ # deliveries: ____ #abortions: ____ # miscarriages: ____
1st day, most recent period: ______ Age at 1st period: ____ Frequency of periods: ____ Length of each: ____
Do you have any concerns about your periods? ☐No ☐Yes: _____________________________________
Do you have any concerns about menopause? ☐No
☐Yes: _____________________________________
FAMILY HISTORY:
Please indicate with a check (√) family members who have had any of the following conditions:
Medical Condition
Mom Dad
Sist
Bro
Daug Son
Other
close
relati
ves
Medical Condition
Alcoholism
Epilepsy (seizures)
Anesthesia problem
Genetic diseases
Arthritis
Glaucoma
Asthma
Heart Attack
(Coronary Artery
Disease)
High Blood Pressure
(Hypertension)
High cholesterol
(Hyperlipidemia)
Kidney diseases
Birth Defects
Bleeding problem
Cancer, Breast
Cancer, Colon
Cancer, Ovary
Lupus
(Systemic Lupus
Erythematosis)
Mental retardation
Cancer, Prostate
Migraine headaches
Cancer (not noted)
Rheumatoid Arthritis
Depression
Stroke
Diabetes, Type 1
(childhood onset)
Diabetes, Type 2
(adult onset)
Eczema
Thyroid disorders
Cancer, Melanoma
Mom Dad
Sist
Bro
Daug Son
Other
close
relati
ves
Tuberculosis
Other:
SOCIAL HISTORY:
SUBSTANCES
Alcohol Use
Do you drink alcohol? ☐No ☐Yes: # drinks/week____
Tobacco Use
Cigarettes
☐Quit: Date _______
Is alcohol use a concern for you or others? ☐No ☐Yes
☐Never
☐Current: Smoker: packs/day____# of yrs____
Other Tobacco: ☐Pipe ☐Cigar ☐Snuff ☐Chew
Are you interested in quitting:
☐No ☐Yes
Drug Use
Do you use any recreational drugs?
☐No ☐Yes
Have you ever used needles?
☐No ☐Yes
EXERCISE:
Do you exercise regularly?
☐No ☐Yes
SOCIOECONOMICS
Occupation: ______________________________________
Education completed: ☐Grade school ☐High school
☐College ☐Graduate school
Years of education ____
☐Engaged ☐Other: ________________
Spouse/Partner’s name: ___________________________
Number of children: _____
Who lives at home with you? _______________________
SEXUALITY
Sexual Activity
Sexually Active:
SAFETY
Do you use seatbelts consistently?
☐No ☐Yes
Do you use a bike helmet regularly?☐NA ☐No ☐Yes
Marital Status: ☐Single ☐M ☐Sep ☐D ☐W
☐Co-habiting
Other concerns?
__________________________________________________
__________________________________________________
☐Yes ☐No ☐Not currently
Is violence at home a concern for you?
☐No ☐Yes
Do you feel safe in your current relationship?
☐NA ☐No ☐Yes
Do you have a gun in your home?
☐No ☐Yes
Other concerns?
__________________________________________________
__________________________________________________
EMOTIONS
Current sex partner(s) is/are: ☐male ☐female
Contraception and Protection
Birth Control method: _____________ ☐None needed
If sexually active, do you practice safe sex?
☐NA ☐No ☐Yes
Have you ever had any sexually transmitted diseases
(STDs)?
☐No ☐Yes
If yes, please include:
_____________________ date _________
_____________________ date _________
Are you interested in being screened for STDs?
☐No ☐Yes
1. In the past year, have you had 2 weeks or
more during which you felt sad, blue or
depressed; or when you lost all interest or
pleasure in things that you usually cared
about or enjoyed?
☐No ☐Yes
2. Have you had 2 years or more in your life
when you felt depressed or sad most days,
even if you felt okay sometimes?
☐No ☐Yes
3. Have you felt depressed or sad much of the
time in the past year?
☐No ☐Yes
IMMUNIZATIONS
Please list your most recent immunizations. Please include your best estimate of the month and year of
each immunization:
Hepatitis A_____
Hepatitis B_____
Tetanus (Td)_____
Measles_____Mumps_____Rubella_____
MMR_____
Varicella (chicken pox) shot_____
Pneumovax (Pneumonia)_____
Other_____
HEALTH MAINTENANCE SCREENING TESTS
Lipid (cholesterol)
Date _______________________
Abnormal?
☐No
☐Yes
Sigmoidoscopy or Colonoscopy (circle one)
Date _______________________
Polyp?
☐No
☐Yes
Women only:
Mammogram
Date _______________________
Abnormal?
☐No
☐Yes
Pap Smear
Date _______________________
Abnormal?
☐No
☐Yes
Bone Density Test
Date _______________________
Abnormal?
☐No
☐Yes
REVIEW OF SYSTEMS:
Please check (√) any current problems you have on the list below.
Constitutional
☐Fevers/chills/sweats
Chest (breast)
☐Breast lump/discharge
Skin
☐Rash or mole change
☐Fatigue/weakness
Respiratory
Neurological
☐Excessive thirst or urination
☐Cough/wheeze
☐Headaches
☐Difficulty breathing
☐Dizziness/light-headedness
☐Unexplained weight loss/gain
Eyes
☐Change in vision
☐Numbness
Gastrointestinal
☐Memory loss
☐Abdominal pain
☐Loss of coordination
Ears/Nose/Throat/Mouth
☐Blood in bowel movement
☐Difficult hearing/ringing in ears
☐Nausea/vomiting/diarrhea
☐Problems with teeth/gums
☐Hay fever/allergies
Psychiatric
☐Anxiety/stress
Genitourinary
☐Problems with sleep
☐Nighttime urination
☐Depression
Cardiovascular
☐Leaking urine
☐Chest pain/discomfort
☐Unusual vaginal bleeding
Blood/Lymphatic
☐Leg pain with exercise
☐Discharge: penis or vagina
☐Unexplained lumps
☐Palpitations
☐Sexual function problems
☐Easy bruising/bleeding
Musculo-skeletal
Other (please specific) __________
☐Muscle/joint pain
_______________________________