ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or shot?
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1 Adult Health History Legal Name: First Last Name you like to be called: Date of Birth: Legal sex: Male Female X Gender: Woman Man Trans Woman Trans Man Non-binary Genderqueer Agender Not Listed: Filling out this form Answering these questions will help your doctor understand your health and how to best treat you. If you need help filling out this form, the clinic staff will help you. GENERAL 1. Are you Single Married Partnered Divorced or Separated Widowed 2. Where did you grow up? 3. What kind of work do you do or, if retired, what did you do? 4. What level of education did you complete? 5. When was the last time you were seen by a primary care doctor? Who did you see? 6. Do you have an Advance Directive or Living Will? 7. Do you have a POLST (Physician Order for Life Sustaining Treatment)? Please bring Advance Directive, Living Will and/or POLST forms to your appointment. ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or shot? No Yes Please write the name of the medicine or shot and the effect you had below. Medicine I am allergic to EXAMPLE: Atenolol What happens when I take that medicine I get a rash Page 1 of 6
2 9. Do you get an allergic reaction (bad effect) from any of the following? No, I have no allergies. Allergic to Latex (rubber gloves) Grass or Pollen Eggs Shellfish Yes. Check all that apply What happens MEDICINES 10. Are you taking any prescription medicines? No, I do not take any prescription medicines. Yes. List your medicines below OR I brought my pill bottles or a list Pharmacy: Phone Number: Medicine name Strength How many pills or doses do you take at a time? or Amount EXAMPLE: Furosemide 20mg 2 morning 1 noon dinner bed Page 2 of 6
3 11. Do you regularly take any over-the-counter, vitamins and nutritional supplements? No Yes Check all that apply and enter Strength or Amount for those you are taking. Name of medicine Pain Reliever (examples: Tylenol, Advil, Motrin, Aleve, Aspirin) Vitamins Antacid (examples: Tums, Prilosec) Herbal medicine, please list: Nutritional supplements, please list: Other, please list: Strength or Amount MEDICAL HISTORY 12. Have you ever had any of the following health problems? Check all that apply. Abnormal pap (not normal pap test) Heart murmur (extra noise heart makes) Allergies Hepatitis (disease that affects the liver) Anemia (low iron, low blood count) High blood pressure Anxiety HIV/AIDS Arthritis Jaundice (skin and eyes turn yellow) Asthma (breathing disease) Kidney disease Blood transfusion Kidney stones Cancer (type: ) Liver disease Cataracts Meningitis Congestive heart failure (CHF) Osteoporosis (weak bones) Bowel disorder Prostate problems Clotting disorder Seizures Chronic obstructive pulmonary disease Sexually transmitted disease Depression (feeling low or blue) Shingles (painful skin rash) Diabetes (high blood sugar) Sickle cell (disorder affecting red blood cells) Emphysema (lung disease) Skin problems GERD (heartburn, acid reflux) Stroke Glaucoma Substance abuse (illegal drugs, drug problem) Gout (joint pain in toes) Thyroid disease Headaches Tuberculosis (TB, lung disease) Hearing loss Ulcers (open sores) Heart attack Urinary problems (problem peeing) Page 3 of 6
4 SURGICAL HISTORY 13. Have you ever had surgery? No, I have never had surgery Surgery Yes. Please list each surgery below. Date FAMILY HISTORY 14. Have any of your family members ever had any of the following health problems? Check all that apply Mother Name Alive? Cancer No known history Diabetes Heart problems High Blood Pressure Stroke Other Thyroid disease Father Sister Sister Brother Brother Page 4 of 6
5 SOCIAL HISTORY 15. Do you drink alcohol? No Yes, please answer the questions below: Wine (glasses a week) How many years? Date quit? Beer (cans a week) How many years? Date quit? Liquor (shots a week) How many years? Date quit? 16. Do you use drugs? (this information is not reported) No Yes, please answer the questions below: Used within the last week? No Yes, how many times? Types of drugs used: check all that apply Marijuana Methamphetamines Cocaine Heroin 17. Have you ever smoked cigarettes, cigars, smoked a pipe, used snuff or chewed tobacco? No Yes, please answer the questions below: Cigarette (packs a day): How many years? Date quit? Cigar (number a day): How many years? Date quit? Pipe (number a day): How many years? Date quit? Snuff (number a day): How many years? Date quit? Chew (number a day): How many years? Date quit? Do you want to quit? I already have quit 18. Do you have sex with Men Women Both I don t have sex If you use birth control, what type do you use? Check all that apply Abstinence Rhythm (calendar tracking) Inserts Implant Condom Tubal Ligation (tubes tied) IUD Vasectomy Injection Withdrawal or pullout method Birth Control Pills Diaphragm Post-menopausal EXERCISE 19. Do you exercise 2 or more days a week? Page 5 of 6
6 IMMUNIZATIONS (Shots) 20. Have you had the following shots? Flu Tetanus Diphtheria (Td) Tetanus-Diphtheria-Pertussis (Tdap)Date Where given HPV (Gardasil) Pneumovax (pneumonia) Zostavax (shingles) Hepatitis A Hepatitis B MMR SPECIALTY SERVICES 21. Are you currently seeing any other doctors? Doctor s Name: Type of Doctor: When Last Seen: Phone Number: Doctor s Name: Type of Doctor: When Last Seen: Phone Number: Doctor s Name: Type of Doctor: When Last Seen: Phone Number: Anything else we should know? Page 6 of 6
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SELF-REPORTING HEALTH HISTORY DATE: DEMOGRAPHIC INFORMATION : Age: Address: City: State: Zip Code: Work Phone: Home Phone: Fax Number: E-mail: Significant Other : Phone: CHIEF COMPLAINT - HISTORY OF PRESENT