KHIEM VU, DO PA
ADULT HEALTH HISTORY FORM
NAME: ______________________________________________________ DOB: _______________________ AGE: _____________
PAST MEDICAL HISTORY: Select all that are applicable. Fill in others that are not listed.
ADD or ADHD
Allergy Testing
Y/N
Panic Attacks
Y/N
Injection Therapy
Y/N
Asthma
Attacks per Month
Atrial Fibrillation
Cardioversion
Y/N
How Many Years
Nebulizer at Home
Y/N
Anticoagulation
Y/N
Allergies
Anxiety
Bronchitis
Cancer (Brain / Bone / Breasts / Colon / Lungs /
Prostate / Skin)
Cerebral Vascular Attack (Stroke or TIA)
Remission / Cured
Chemo / Radiation /
Surgery
Oncologist:
Deficits
Chronic Pain
COPD
Last Spirometry
Last Stress Test Date
Home Oxygen
Y/N
Stress Test Result
Coronary Arterial Disease
Treatment
Diabetes Mellitus Type I / II
Diagnosed Date
Insulin
Oral Medications
GERD (reflux)
Peptic Ulcer
Y/N
Endoscopy Date
Headache (Cluster / Migraine / Tension)
Headaches per Month
Heart Failure
EF if known
Implanted Defibrillator
Y/N
Controlled
Y/N
Endoscopy Date
Colonoscopy Date
Stenting:
# of Vessels
Cardiologist:
Valve Replaced
Aortic / Mitral
Valve type:
Prosthetic /Mechanical
Hemorrhoids (External / Internal)
Inflammatory Bowel Disease (Crohn’s / Ulcerative
Colitis)
Kidney Disease
Dialysis
Y/N
Kidney Stones
Myocardial Infarction (Heart Attack)
Osteoarthritis
Bypass Surgery
# of Vessels
Joint (s) Affected
Pacemaker Implanted
Rheumatoid Arthritis
Joint (s) Affected
Skin Disease (Psoriasis / Rash )
Tremor
Etiology ?
Valvular Replacement
Date Replaced
Other
Other
Other
Other
PREVIOUS SURGERIES:
Year
Surgery
Hospital
FAMILY HISTORY: Has any of your family member(s) ever had any of the following conditions?
Disease
Father
Mother
Sibling
Other
Alzheimer
Anemia: Pernicious / Thalassemia / Iron
Asthma
Cancer: Brain / Breasts / Colon / Cervical / Lungs / Lymphoma / Prostate / Skin
COPD
Cerebral Vascular Accident
Diabetes Type I / II
High Blood Pressure
High Cholesterol
Kidney Problems requiring Dialysis
Gastrointestinal : Crohn’s / Ulcerative Colitis / Peptic Ulcer / Polyps
Liver Disease: Hepatitis / Cirrhosis
Osteoarthritis
Rheumatoid Arthritis
Skin Problems: Psoriasis / Rash
SOCIAL HISTORY:
Occupation: ______________________ Employer : ________________If Retired, Prior Occupation: ________________
Tobacco Use?  N
Y
If yes, what? ________________ How much? _______________ How long? __________
*If you had a history of tobacco use, but quit, please give quit date: __________________________________________
Alcohol Use?
N
Y
If yes, what? ________________ How much? _______________ How long? __________
Illegal Drug Use?  N  Y If yes, what? ________________ How much? _______________ How long? __________
Marital Status: Single 
Engaged 
Are you sexually active?  N
Y
Married 
Do you exercise?  N
Y
Y
Separated 
Current sex partner(s)?  Male
Have you ever had a sexually transmitted disease?  N
Do you have children?  N
Widowed 
Y
Divorced 
 Female
Birth Control Method: _____________________
If yes, how many? __________________
If yes, how frequently? ___________________
HEALTH MAINTENANCE & SCREENING TEST:
DATE
NORMAL
ABNORMAL
NEXT SCHEDULED
Bone Density
Colonoscopy
Pap Smear (female)
Mammogram (female)
Prostate (male)
Digital Rectal Exam
IMMUNIZATIONS & TESTS: What vaccinations have you received in the past?
 Hepatitis A
 Hepatitis B
 Meningococcal
Positive TB skin test?
 No
 Flu Shot
 MMR
 Tetanus (TD or Tdap)
 Pneumonia Shot
 Shingles Shot
 Chicken Pox
 Yes Chest X-ray Result:  Normal  Abnormal If Abnormal, treated?
 Polio
 No
 Yes
ALLERGIES: List any allergies to medications and/or foods.
Do you have an Advance Directive?  N  Y
** If yes, please provide a copy for your chart.
Do you have an appointed Power of Attorney or Medical Power of Attorney?  N  Y ** If yes, please provide a copy for your chart.
CURRENT MEDICATIONS:
Name
*Please use additional form if necessary.
Dose/Strength
Frequency
CURRENT MEDICATIONS:
Name
Dose/Strength
Frequency