Adult Health History Questionnaire
Name:
Date Of
Birth:
I
I
Today's
Date:
I
lnglewood
Family
Health, PLLC
I
Please review the sections on both sides of this form. lf this is your first visit to this
physician, please fill this out in full. lf you are not a new patient to this physician please
update this form with any new information since your last visit. ln all cases please
complete the Review Of Symptoms And Health Problems section below.
=
E
E
Male
Female
s
Number of Children
tn
What specific
EI
=
o
o
G,
A
E
tr
lrJ
o
z
vt
o
o-
E
E single
E Married
Domestic Partner
o
3
EI
UJ
E,
Occupation
Ages of Children
HEALTH PROBTEMS do
you want to talk about when you are seen in the clinic?
Please mark any of the following symptoms that are CURRENTTY affecting you:
METABOLIC/ENDOCRINE
CONSTIUTIONAL
tr
tr
tr
tr
Fever
Fatigue
Weight change
E
Gain
E
Loss
other:
HEAD, [YES, EARs, NOST, THROAT
tr
tr
D
tr
Severe headaches
Ear or hearing trouble
Vision changes
tr
tr
tr
tr
Excessive
thirst
Excessive hunger
Cold
intolerance E
Heat intolerance
other:
NERVOU'sYSTIM
tr
tr
tr
Dizziness
Excessivenervousness
other:
other:
DERMATOLOGY/SKIN
1a
II
Next of Kin
n Divorced D widowed
RESPIRATORY/LUNGS
tr
tr
tr
tr
Daily cough
Wheezing
Shortness of breath
other:
HEART
tr
tr
tr
Chest pain
tr
Leg swelling
other:
Constipation
Diarrhea
tr
BOilISfOTNTS/MUSCTES
Joint pain or swelling
I
tr
!
Muscle weakness
other:
ELOOD
I
tr
tr
Excessive bleeding
Excessive bruising
other:
URINARY
tr
n
tr
tr
tr
Blood in urine
Unusual discharge
Leakage of urine
Erectile Dysfunction
other:
other:
IMMUNOLOGY
Food allergies
tr
tr
ltching
other:
Clotting problems
STOMACH/INTESTINAT
Frequent nausea or vomiting
tr
tr
tr
I
Rashes
Heart palpitations (skipped beats)
other:
VASCULAR
I
tr
tr
!
tr
Environmentalallergies
other:
GYITCOLOGY
Changes in menstrual flow
tr
tr
n
tr
Excessive cramping
Vaginal discharge
other:
There have been no changes in the information below since my last visit.
lrl
=
=
ul
o
G,
ALTERGIES
List any medications or other substances that you are allergic to or have had a reaction
NONE
N
NONE
tr
tol
J
(J
oUJ
=
PRESCRIPTION MEDICATIONS
List a
rescri
n medications
u are currentl
Med ication
Dosage
taki
bottles or a list with
bri
Frequency
if possible):
Medication
trequency
NON-PRESCRIPTION MEDICATIONS
List any non-prescription medications (laxadves, vitamins, aspirin, antacids, cold remedies, etc)you are currently taking
VACCINATIONS (lnclude year
c,
ts
uI
I
tr
tr
tr
n
n
n
n
tr
tr
n
tr
tr
tr
n
tr
n
n
n
n
Flu
Shingles
HPV
Tetanus/Tdap
Meningitis
Pneumonia
Hep A/B
tr
a
u
tr
c_
tr_
tr_
Preventive History (Year or
Anemia
Asthma
Emphysema
High cholesterol
Heart disease
High blood pressure
Kidney stones
Liver disease, jaundice, hepatitis
M igraine
Serious injury or accident
Sugar Diabetes
Thyroid gland trouble
Tuberculosis or positive skin test to TB
Sexually transmitted disease
_Last
_Last
_
_
_
o
F
J
=
sI
o
Smear
tr
Bone Density tr
Last Colonoscopy tr
Last Mammogram tr
Last PSA Test
n
n
Alcohol or substance abuse
Breast Cancer
Ovarian Cancer
Colon Cancer
Prostate Cancer
Age_
Date
Type-
Date
E Cigarettes E Pipe E Cigar E
Sexual Orientafion (Do you have sex with):
n Men E Women E Both E Not sexually active
Chew
Daily Amount:
n
n
Caffeinated Beverages:
Cups per day
Do you use contraception?
Do you practice safe sex?
Type
Exercise:
Type_
Alcohol: Average drinks/week:
n
Recreational Drug Use:
Hours of sleep per night
Type Used
tr
High blood pressure
Pregnancy: How many?_
History of sexual or physical abuse
_
n
n
Diabetes
High cholesterol
Years:
tr
Heart attack or heart disease
Mental or emotional disease
Surgeryr Type
!
Past
Abnormal
n
n
n
n
tr
Pap
Sleep Problems
Urinary Problems
Cancer:
Normal Abnormal
List your blood relatives who have had any of the followinS?
Tobacco:
cc
N/A)
Mood problems
Menopause:
!
Last tuber€ulosis skin test datel
check if you have had any of the following?
n
o
F
ttl n
tr
f=
I
if known)
NONE
Past E current
Amount
Do you diet?
_
Meals per day
_