Adult Patient Health History

The information completed on this questionnaire will become a confidential part of your medical record. If you do not want to answer a question, leave it blank and discuss it privately with your doctor at your visit.

Today's Date (required)

Appointment Date (required)

Previous Physician

First Name (required)

Last Name (required)

Middle Initial

Date of Birth (required)

Allergies

Medications

List/Describe

Other Allergies

Medical History

Medications

List all medications you are currently taking which have been ordered by a doctor (including inhalers) and all over the counter drugs, vitamins or herbs. Please list prescribed medications first.

Your pharmacy name and location

Pharmacy Phone Optional - Format: 123-456-7890 or (123) 456-7890

Please enter a valid US phone number.

Name of Medicine/Dose/Frequency:

10.

11.

12.

13.

14.

15.

16.

17.

18.

Immunizations

For Adults:

Flu (once annually)

Pneumonia (Once every 5 years)

Tetanus

Shingles (Zostavax)

Illnesses

Check major, significant illnesses which apply to you:

Liver Disease

Osteoporosis

Migraine Headaches

Stroke

Thyroid Disease

Tuberculosis/TB

Ulcers

Gallbladder disease

Other Illnesses:

Surgical

List the year of any operations/procedures you have had:

Appendix Surgery

Breast growth removal

Carpal tunnel

Cataract Removal

Cesarean section delivery

Colonoscopy

D&C

Gall bladder surgery

Gastroscopy

Heart catheterization/surgery

Hernia

Hip Surgery

Hysterectomy

Knee Surgery

Nasal/Sinus Surgery

Plastic Surgery

Polyp removal from intestine

Prostate surgery

Thyroid surgery

Tonsils

Tubal Ligation

Vasectomy

Other Surgery 1

Year

Other Surgery 2

Year

Hospitalizations

List any other hospitalizations:

Reason 1:

Year 1:

Reason 2:

Year 2:

Reason 3:

Year 3:

Reason 4:

Year 4:

Trauma/broken bones/serious accidents

Trauma 1:

Year 1:

Trauma 2:

Year 2:

Trauma 3:

Year 3:

Other physicians

List any other doctors (specialists, etc.) you have seen:

Family History

Are you adopted?

Yes

Relative's approximate age at time of death

List the cause of death for those who died prior to age 50:

Father

Mother's father

Father's father

Mother

Mother's mother

Father's mother

Any Sibling

Family illnesses

Check any illnesses which have occurred in a blood related brother (b), sister (s), mother (m), father (f) or grandparent (g):

Alcoholism/Substance Abuse

Alzheimer's/Dementia

Cancer (Breast)

Cancer (Colon)

Cancer (Prostate)

Cancer (other)

Diabetes

Emotional/Mental Illness/Suicide

High Blood Pressure

Heart attack prior to age 50

Osteoporosis

Stroke

Tuberculosis

High Cholesterol

Are there other family illnesses that we should know about?

Social History

Occupation

Marital Status

Married

Single

Widowed

Divorced

Other

Who do you live with now?

Number of children and year of birth:

# of Sons:

Year of Births:

# of Daughters:

Year of Births:

If you have minor children, do they live in your household?

Yes

Not applicable

Do you wear seatbelts?

Yes

Do you travel extensively outside the US (other than vacations)?

Yes

Smoking History

What is your smoking status? (required)

Never

Past

Current

Alcohol Use

On average, how many alcoholic drinks (1 drink= 12 oz. beer, 10 oz. wine cooler, 5 oz. wine, 1.5 oz liquor) do you consume?

Non-drinker

1-2 per week

1-2 per day

3 or more per day

Other

a. Do you drink every day?

Yes

b. Have you ever thought you had a problem with drinking?

Yes

Diet and Exercise

Do you follow a special diet?

Yes

Indicate the number of days per week you participate in the following exercise:

Walking

Biking/exercise machine

Organized sports

Running

Swimming

Weight lifting

Aerobics

Other

Do you need help from your doctor for a problem related to physical, verbal or mental abuse?

Yes

Are you at risk for AIDS/HIV?

Yes

Unknown

(Homosexual, Bisexual, Multiple Sex Partners, Needle drug use other than insulin)

Any street drug use?

Yes

Do you need help from your doctor for an issue related to drugs?

Yes

Life Style and Health Risks

Men and Women of all ages:

Have you had a tetanus/diphtheria shot within the last 10 years?

Yes

Unknown

Have you had two Measles, Mumps, Rubella shots or the diseases as a child?

Yes

Unknown

Have you had the following shots?

Hepatitis A (Transmitted by food)

Yes

Hepatitis B (Transmitted by body secretions)

Yes

Have you had your cholesterol checked within the last 5 years?

Yes

Unknown

Do you take a daily aspirin?

Yes

Do you wear your seat belt?

Always

Sometimes

Never

Have you had chicken pox?

Yes

Women's Health

Do you take calcium supplements?

Yes

Have you had a Pap Smear within the past 2 years?

Yes

Have you had an abnormal Pap Smear?

Yes

Do you usually do self breast exams?

Yes

Have you had a professional breast exam within the last 3 years?

Yes

If 40 or above, have you discussed mammography with your doctor?

Yes

If 50 or above, have you had a mammogram within the last 2 years?

Yes

Have you ever had a bone density?

Yes

What age did you start menstruating?

When was your last menstrual period?

Have you ever gone more than 3 months without a period?

Yes

When did you become menopausal?

Not applicable

Yes

Have you ever taken HRT? (hormone replacement therapy)

Yes

Have you had any abnormal bleeding?

Yes

Men's Health

When was your last prostate exam? (rectal exam)

When was your last PSA test? Year

Do you know the result?

Do you do a yearly testicular self-exam?

Yes

Have you had any history of urinary problems?

Yes

Men and Women over age 50 only

Have you had your stool checked for blood within the last year?

Yes

When was your last colonoscopy? (Year)

Was anything seen (ie: polyps, etc.?)

Of the best of my knowledge, the above information is complete and correct. I understand that reporting incomplete or inaccurate information can be dangerous to my health condition. I understand that I am solely responsible for any errors or omissions that I may have made in the completion of the form. I understand that it is my responsibility to inform my doctor of any changes in my health conditions.

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