Adult Health History
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- Colleen Warren
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1 Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit and intake process with our office. If you are uncertain or uncomfortable with a question it can be left blank. IMMUNIZATIONS: Check off any vaccinations you have had. Add year, if known. Check the box if you don t know the information. Tetanus (Td) With Pertussis (Tdap) Varicella (Chicken Pox) shot or illness Pneumovax (pneumonia) Influenza (flu shot) Hepatitis A Hepatitis B MMR Meningitis Zostavax (shingles) HPV MEDICATIONS: Please list (or show us your own printed record) all prescriptions and non-prescription medications, vitamins, home remedies, birth control pills, herbs, inhalers, etc. Use the back of this form if you need more room and let us know you wrote there. TAKE NO MEDICATIONS Medication Dose (e.g. mg/pill) How many times per day? Allergies or intolerance to medications (include type of reaction): NONE HEALTH MAINTENANCE SCREENING TESTS: Lipid (cholesterol) Date Abnormal? No Yes Fasting Blood sugar 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
2 PERSONAL MEDICAL HISTORY: Do you have now (current) or have you had (past) any of the following conditions? NONE Condition Code Current Past Comments Alcohol / Drug abuse / Allergy (Hay Fever) Anemia Anxiety 300 Arthritis (Rheumatoid) 714 Arthritis (Osteoarthritis) Asthma Bladder / Kidney Problems Blood Clot (leg) Blood Clot (lung) Blood Transfusion V58.2 Breast Lump (benign) Cancer Breast Cancer Colon Cancer Other Type Cancer Ovarian 183 Cancer Prostate 185 Cataracts Chicken Pox 52.9 Colon Polyp Coronary Artery Disease 414 Depression 311 Diabetes (adult onset) 250 Diabetes (childhood onset) Diverticulosis Emphysema Fractures (broken bones) Gallbladder Disease Gastroesophageal Reflux (Heartburn/GERD) Glaucoma Gout Gynecological Conditions (Endometriosis) Gynecological Conditions (Fibroids) Gynecological Conditions (Other) Heart Attack Hepatitis Type A 70.1 Hepatitis Type B 70.3 Hepatitis Type C Where?
3 Personal Medical History Continued: Condition Code Current Past Comments Hepatitis Other High Blood Pressure High Cholesterol 272 Hip Fracture Irritable Bowel Syndrome Kidney Disease / Failure 586 Kidney Stones 592 Liver Disease Migraine Headaches Osteoporosis 733 Pneumonia 486 Prostate (enlargement) 600 Prostate (nodules) Seizure / Epilepsy Skin Condition (Eczema) Skin Condition (Psoriasis) Skin Condition (Abnormal Moles) Sleep Apnea Stomach Ulcer Stroke Thyroid (Nodule) 241 Thyroid High (Overactive) / Hyperthyroidism Thyroid Low (Underactive) / Hypothyroidism Surgical Procedure Code Yes Year Comments Abdominal Surgery Appendectomy (appendix removal) Back Surgery (lumbar) Biopsy (location) Breast Biopsy Breast Surgery Colonoscopy Coronary Bypass Coronary Stent EGD (Stomach Endoscopy) Cataract Gallbladder Removal Circle: Laparoscopic Heart Surgery (other than coronary bypass) Surgical Procedures Code Yes Year Comments
4 Mother Father Sister(s) Brother(s) Mom s Mom Mom s Dad Dad s Mom Dad s Dad Continued Hip Surgery Hysterectomy (total, including ovaries) Hysterectomy (partial, ovaries left) Knee Surgery LEEP (Cervix Surgery) Neck Surgery Ovary Ligation ( Tubal ) Ovary Removal Vasectomy Sigmoidscopy Sinus Surgery Circle: Laparoscopic Vaginal Abdominal Circle: Laparoscopic Vaginal Abdominal Adopted Yes No (Please Circle) If yes and you do not know your family history skip this section and continue to page 5 (Other Health Issues) FAMILY HISTORY Indicate which relative has had the following diseases (parents and siblings are most important). Disease No significant history known Alcoholism / Drug abuse Alzheimers Asthma Autoimmune Disease Bleeding or Clotting Disorder Cancer Breast Cancer Colon Cancer Other Type Cancer Ovarian Cancer Prostate Colon Polyp Coronary Artery Disease (e.g. heart attack, angina) Depression / Suicide / Anxiety Diabetes (childhood onset) Diabetes (adult onset) Other Relative Comments
5 Mother Father Sister(s) Brother(s) Mom s Mom Mom s Dad Dad s Mom Dad s Dad Disease Continued : Emphysema (COPD) Genetic Disorder (explain) Glaucoma Heart Disease (CHF) Heart Disease (Other) Hepatitis B or C High Blood Pressure - Hypertension High Cholesterol Hip Fracture Hypothyroidism / Thyroid Disease Kidney Disease Kidney Stones Macular Degeneration Migraine Headaches Osteoporosis Other Relative Comments OTHER HEALTH ISSUES: Tobacco Use Smoke cigarettes: Never No Yes Quit date: How many years did you smoke? Approximately how many packs a day did you smoke? Current smoker: Packs/day: # of years: Other tobacco: Pipe Cigar Snuff Chew Alcohol Use Do you drink alcohol? No Yes # of drinks/week: Drug Use Do you use marijuana or recreational drugs? No Yes Have you ever used needles to inject drugs? No Yes Exercise: Do you exercise regularly? Yes No What form of exercise? How long (minutes)? How often? Diet: How would you rate your diet? Good Fair Poor Would you like advice on your diet? No Yes Sexual Activity Sexually involved currently: No Yes Sexual partner(s) is/are/have been: male female Birth control method (circle below all that apply) None needed Condom, pill, diaphragm, IUD, vasectomy, other
6 Have you completed an Advance Directive or living will? No Yes Is violence at home a concern for you? No Yes Have you completed an Advance Directive? SOCIAL HISTORY: Occupation (or prior occupation): retired/unemployed/leave of absence/disabled (circle one if applicable) Employer: Years of education or highest degree: Marital status (circle one): single, partner, married, divorced, widowed, other: Spouse/partner s name: Number of children: Sports, hobbies: WOMEN S HEALTH HISTORY: Total number of pregnancies: Number of births: Date (month/day if known) of last menstrual period if you are still menstruating: Age at beginning of periods (menstruation): Age at end of periods (menopause): Thank you for taking the time to fill this out.
Adult Health History for NEW Patients
Adult Health History for NEW Patients Name Date Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient
Adult Health History for NEW Patients
Adult Health History for NEW Patients Name Date Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient
Adult Health History for NEW Patients
Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is
Adult Health History for New Patient
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Patient Information Form
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IMMUNIZATIONS: Check off any vaccinations you have had. Add year if known. Check the box if you don t know the information
Health History for NEW Patients Name: Date of Birth: Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. Please fill in all five
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PATIENT NAME TODAY S DATE DATE OF BIRTH
Adult Health History Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is a shorter update
Adult Health History New Patient
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The following questions will help us determine what problems you have and what needs to be done prior, during or after your visit. Please complete this at least 3 days before the visit and email or fax
Comprehensive Patient History Form
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ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or shot?
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Clinic Adult Patient Demographics
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Adult Health History Form Preferred Name: 1
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NOTICE TO OUR PATIENTS
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FROST FAMILY MEDICINE
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PATIENT HEALTH HISTORY
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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