Adult Health History Form Preferred Name: 1
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- Peregrine Reeves
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1 Adult Health History Form Preferred Name: 1 Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. Thank you! Main reason for today s visit: Other concerns: Referred by: In the past 2 weeks, have you been bothered by: Little interest or pleasure in doing things? Feeling down, depressed or hopeless? Thoughts of hurting yourself or someone else? Thoughts things might be better if you weren t here? REVIEW OF SYMPTOMS: Please mark the box and/or circle any persistent symptoms you have had in the past few months. Chronic pain. If yes, where? Tremors or worrisome movements Headache Numbness / tingling Chest pain / discomfort Shortness of breath or sensation of choking Gender-identity concerns Nausea and/or vomiting Beginning when? Fainting/Dizziness Memory loss Unsteady gait Heart palpitations Hot flashes / night sweats Insomnia or sleep problems Other OB/Gynecologic Pregnant If yes, Due Date Perimenopause/Menopause Infertility Concern with sexual function Postpartum If yes, Delivery Date Nursing Weight loss/gain Pelvic pain Psychiatric Anxiety/stress Irritability Frequent crying Anger Difficulty concentrating Suicidal thoughts Apathy/Feeling like things don t matter Pre-menstrual symptoms (anxiety, irritability, mood changes) Seeing/Smelling/Hearing/Feeling things that aren t there *Other persistent symptoms or concerns you would like to discuss:
2 Adult Health History Form Preferred Name: 2 Preferred Pharmacy (include location): Primary care provider (leave blank if none): Phone number: Address: MEDICATIONS: Please all prescriptions and non-prescription medications, vitamins, birth control pills, herbs, etc. Include dose and frequency. Use the back of this form if you need more room. I TAKE NO MEDICATIONS or SUPPLEMENTS (including birth control) Allergies or intolerance to medications or food (include type of reaction) NONE PERSONAL MEDICAL HISTORY Yes Comments (onset, persistent or resolved, major treatments, etc) Anemia Asthma/Breathing problems Autoimmune Disorder Bladder/Kidney problems Cancer Chronic Fatigue Syndrome Diabetes (adult, childhood, gestational?) Fibromyalgia Head Injury Loss of consciousness? Heart Attack or other heart High Blood High Cholesterol HIV or AIDS Irritable Bowel Syndrome Kidney disease Liver Disease or Hepatitis Migraine headaches Seizures/Epilepsy Sleep apnea Stroke Thyroid Disease (overactive or underactive?) Alcohol/Drug abuse Other addictions (i.e., gambling, food, sex, etc.) Anxiety Obsessive-Compulsive Traits Eating Disorder Self-harm (cutting, etc.) Bipolar disorder/manic- Schizophrenia Personality Disorder PTSD ADHD/ADD Autism SURGICAL HISTORY Please note any surgeries. List dates and any abnormal finding or complications.
3 Adult Health History Form Preferred Name: 3 NONE Have you ever used psychiatric medications? (Please list prior meds) How many times have you been hospitalized for psychiatric reasons? Ever hurt yourself on purpose? Ever had suicide attempts? How else have you treated mental health concerns now or in the past? Lifestyle: How often do you exercise/what type? Describe your typical sleep pattern: Diet: How would you rate your diet? Good Fair Poor Dietary restrictions? Caffeine intake: Tobacco Use : Never t currently How? Cigarettes Pipe Cigar Snuff Chew (If you never smoked please go to alcohol use question now) Quit date: How many years did you smoke? How many packs/day did you smoke? Current smoker: Packs/day: # of years: Are you interested in quitting at this time? Alcohol Use: Do you drink alcohol? # of drinks/week: Beer Wine Liquor Are you interested in quitting at this time? Drug Use: Do you use marijuana? Other recreational drugs? Please list types, frequency, and when use began Are you interested in quitting at this time? If you previously used drugs and stopped, when did you quit? OB/GYN HEALTH HISTORY: Total number of pregnancies: Infertility problems or treatment: Number of live births: Miscarriages or terminations (before 20 weeks): Miscarriages or terminations at or after 20 weeks: Postpartum complications (infection, chronic pain, sick baby, etc): History of a traumatic pregnancy/birth/infertility experience? Date (month/day if known) of last menstrual period if you are still menstruating: How often do you get your period? Are they regular? Age at end of periods (menopause): Year: Do you notice your mood changes significantly with your cycle? Do you plan to pursue pregnancy within the next year?
4 Adult Health History Form Name: 4 Adopted Yes No (Please Circle) If yes and you do not know your biological family history skip the next section and continue at Social History. Other Relatives FAMILY HISTORY Alzheimer s/dementia Chronic Fatigue Syndrome Diabetes Fibromyalgia Heart Problems High Blood Pressure Thyroid Disease Kidney Disease Migraine Headaches Parkinson s Sudden death Mother (Biological) Father (Biological) Sister(s) # Brother(s) # Mom s Mom Mom s Dad Dad s Mom Dad s Dad 4 (*including your children) Comments Include partner below Alcohol/Drug abuse Other addictions (i.e., sex, gambling, etc.) Anxiety OCD Suicide Bipolar disorder/ Manic- Schizophrenia Personality Disorder PTSD ADHD/ADD Autism SOCIAL HISTORY: Do you have a religion or spiritual practice? : Please list previous faiths: Is violence at home a concern for you now? Has violence at home ever been a concern? Have you ever been an abusive toward others? I don t have guns. If you have guns in your home, are they locked up? Occupation (or prior occupation): retired/unemployed/leave of absence/disabled (circle one) Last grade completed or highest degree: Sexual orientation: Homosexual Bisexual Pansexual Heterosexual Transgender? Preferred pronoun: he/she/they Relationship status (circle one): single, partnered, married, divorced, widowed, other: Current or former spouse/partner s name: Names and ages of children: Who lives at home with you (include pets, friends, temporary longterm guests)? Please note anything else you d like to include:
5 Adult Health History Form Name: 4 Thank you for taking the time to fill this out. 5
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