American College of Physicians | Internal Medicine | ACP
Patient Name: __________________________________
Adult Extended History Form Date of Birth: __________________________________
Medical Record Number: _________________________
Date: ____________________________
Past Medical History Past Surgical History Immunizations
( See Adult Summary Form ( See Adult Summary Form ( See Health Maintenance Flowsheet
Social History Nutritional/Exercise Assessment
Tobacco Marital Status Typical Breakfast
( No ( Single ____________________________
( Yes ______ppd x______years ( Married
( Civil Union Typical Lunch
Stage ( Divorced ____________________________
( Precontemplation ( Widow(er)
( Contemplation Typical Dinner
( Action Children ____________________________
( Consolidation ( Boy(s) Age(s) _______
( Relapse ( Girl(s) Age(s) ________ Usual Snacks/Beverages
____________________________
Occupation(s)
ETOH ______________________ Level of Activity (Exercise)
( No ( None ( Occasional
( Yes ____C ____A ____G ____E Religious Preference ( Regular ( Vigorous
______________________
Type of Exercise:
Illicit Drug Use ____________________________
( No ( Yes Advance Directive
( Yes (No
Types/Quantity/Frequency ( No Interval Change
_____________________________ See Adult Summary Form
Family History Notes
Mother Father
( Alive, Age ____ ( Alive, Age ____
( Deceased, Age ____ of ___________ ( Deceased, Age ____ of __________
Sister(s) Brother(s)
( Alive, Age ____ ( Alive, Age ____
( Deceased, Age ___ of ____________ ( Deceased, Age ____ of __________
( Alive, Age ____ ( Alive, Age ____
( Deceased, Age ___ of ____________ ( Deceased, Age ___ of ___________
( Others ( Others
( No Interval Change;
See Adult Summary Form
Notes
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature ______________________________________________________________ Date ______________
................
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