ADULT HEALTH HISTORY Patient Initials Today’s Date Date of Birth In the past two weeks, have you been bothered by: Little interest or pleasure in doing things? Feeling down, depressed, or hopeless? Age Gender Yes Yes No No Review of Symptoms Please check and circle any persistent symptoms you have had in the past few months. Read through every section and check “no problems” if none of the symptoms apply to you. List other concerns above. GENERAL Unexplained weight loss / gain Unexplained fatigue / weakness Fall asleep when sitting, day Fever or chills NO problems Palpitations Muscle / joint pain NO problems NO problems RESPIRATORY ENDOCRINE Cough / wheeze Heat or cold sensitivity Loud snoring / altered breath NO problems Shortness of breath w/ exertion SKIN New or change in mole Rash / itching NO problems BREAST Swollen glands GASTROINTESTINAL Heartburn / reflux / indigestion Constipation NO problems NO problems Easy bruising NO problems Blood or change in bowel movement Breast lump, pain, nipple discharge EARS/NOSE/THROAT HEMATOLOGIC / LYMPHATIC NO problems NEUROLOGICAL Headache Memory loss GENITOURINARY Nosebleeds, trouble swallowing Leaking urine Dizziness/Fainting Frequent sore throats, hoarseness Blood in urine Numbing/tingling Hearing loss / ringing in ears Nighttime urination or increased frequency Unsteady gait NO problems Discharge: penis or vagina Frequent falls Concern w/ sexual function NO problems EYES Change in vision/ eye pain/ redness NO problems CARDIOVASCULAR Chest pain / discomfort Adult Health History NO problems ALLERGIC / IMMUNE Hay fever / allergies MUSCULOSKELETAL Neck pain Back pain Frequent infections NO problems Updated: March 28, 2024 1 ADULT HEALTH HISTORY PSYCHIATRIC NO problems Anxiety / stress / irritability Sleep problems Problem with menstrual periods Hot flashes / night sweats WOMEN ONLY Premenstrual symptoms (bloating, cramps, irritability) Lack of concentration NO problems IMMUNIZATIONS: Check off any vaccinations you have had. Add year, if known. Tetanus (Td) Tetanus w/ Pertussis (Tdap) Varicella (Chicken Pox) shot or illness Pneumovax Influenza (flu shot) Hepatitis A Hepatitis B MMR Zostavax (shingles) Zostavax (shingles) WOMEN’S HEALTH HISTORY Total number of pregnancies Date of last menstrual period (if still menstruating) Age at beginning of periods Age at end of periods (menopause) MEDICATIONS Please list all prescriptions and non-prescription medications, vitamins, home remedies, birth control pills, herbs, inhalers, etc. I take no medications MEDICATION Adult Health History DOSE (e.g. mg/pill) HOW MANY TIMES PER DAY Updated: March 28, 2024 2 ADULT HEALTH HISTORY ALLERGIES Any allergies or intolerance to medications (include type of reaction)? I have no allergies PERSONAL MEDICAL HISTORY: Do you have (now) or have you had (past) any of the following conditions? NONE Condition Now Past Condition Now Alcohol / Drug use Emphysema Allergy (Hay Fever) Gastroesophageal Reflux Anemia Heart Attack Anxiety Hepatitis Arthritis High Blood Pressure Asthma High Cholesterol Bladder / Kidney Problems Kidney Disease / Failure Blood Clot Migraine Headaches Blood Transfusion Osteoporosis Cancer Pneumonia Cataracts Prostate problems Chicken Pox Sleep Apnea Coronary Artery Disease Stomach Ulcer Depression Stroke Diabetes Thyroid problem Adult Health History Updated: March 28, 2024 Past 3 ADULT HEALTH HISTORY Diverticulosis Other: SURGICAL HISTORY: Have you had any surgeries? Surgical Procedure Yes (list below) No Year FAMILY HISTORY Are you adopted? Yes (If yes, and you do NOT know your family history, please skip to section “Other Health Issues”.) Disease Mother Father Sister Brother Mom’s Mom’s Dad’s Mom Dad Mom Dad’s Dad No Other Relatives No significant history known Alcohol / Drug abuse Allergic Disorder Cancer Diabetes Gastrointestinal Disorder Heart Disease Hypertension Kidney Disease Mental Illness Migraine Headache Myocardial Disorder Respiratory Disorder Seizure Disorder Stroke Syndrome Tuberculosis Adult Health History Updated: March 28, 2024 4 ADULT HEALTH HISTORY OTHER HEALTH ISSUES Tobacco Use Smoke cigarettes? Yes No Never (If you never smoked, please skip to alcohol section) Quit Date: Current smoker: How many years did you smoke? Packs per day: How many packs a day did you smoke? Number of years: Other tobacco: Pipe Cigar Snuff Chew Alcohol Use Do you drink alcohol? Yes Beer No Wine Liquor Number of drinks per week: Number of drinks per day: ____________________ Drug Use Have you used marijuana or recreational drugs? Yes No Have you ever used needles to inject drugs? Yes No Diet Are you following a food limiting diet, like low carbohydrates, Vegan, ect. If so what: ____________________ Are you following a physician prescribed diet? If so what: ___________________________________________ How would you rate your diet? Good Would you like advice on your diet? Fair Poor Yes No Exercise Do you exercise regularly? Yes No What kind of exercise? How long? (minutes) How often? Safety Do you use a bike helmet? Yes No No bike Do you use seatbelts consistently? Yes No Does your home have a working smoke detector? Yes No If you have guns in your home, are they locked up? Yes No Is violence in your home a concern for you? Have you completed any of the following: (please check all that apply) Adult Health History No guns Yes No Updated: March 28, 2024 5 ADULT HEALTH HISTORY Advance Directive for Healthcare (ADHC) Living Will SOCIAL HISTORY Occupation (or prior occupation): If not currently employed, please check one: Retired Unemployed Leave of absence Disabled Employer: Years of education or highest degree: Marital status (please check one): Single Partner Married Divorced Widowed Other: Spouse/partner name: Number of children: Age(s) if under 18 years: Who lives at home with you? Leisure activities, group involvement, religion, volunteer work, recent travel: Adult Health History Updated: March 28, 2024 6
