Adult Health History Form - Unity Care NW
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CURRENT HEALTH & MEDICAL HISTORY -- ADULT: AGE 19 AND UP Page 1
Please fill in the blanks OR circle all items that apply
Patient name:_________________________________________________________ Date of Birth____________________________ Age:____________
PAST OR PRESENT PHYSICAL & MENTAL ILLNESSES/SURGERY/HOSPITALIZATIONS
Year Year
1. ______________________________________ ___________ 5.__________________________________ ________
2.______________________________________ ___________ 6.___________________________________ _________
3.______________________________________ ___________ 7.___________________________________ _________
4.______________________________________ ___________ 8.___________________________________ __________
| |
|FAMILY HISTORY |
Disease or Condition
|
Father |
Mother |
Grandparent |
Sibling |
Child
|
Other
| |Alcoholism | | | | | | | |Allergies | | | | | | | |Anxiety | | | | | | | |Asthma | | | | | | | |Bipolar Disorder | | | | | | | |Bleeding Disorder | | | | | | | |Cancer: Breast | | | | | | | |Cancer: Cervical | | | | | | | |Cancer: Colon | | | | | | | |Cancer: Lung | | | | | | | |Cancer: Ovarian | | | | | | | |Cancer: Prostate | | | | | | | |Cancer: Other | | | | | | | |Clotting Disorder | | | | | | | |Depression | | | | | | | |Diabetes | | | | | | | |Drug problem | | | | | | | |Epilepsy/Seizures | | | | | | | |Headaches | | | | | | | |Heart Problems | | | | | | | |High Blood Pressure | | | | | | | |Migraines | | | | | | | |Schizophrenia | | | | | | | |Stroke | | | | | | | |Thyroid problem | | | | | | | |Other | | | | | | | |
CURRENT MEDICATIONS Pharmacy ____________________________________
List all prescriptions, herbs, vitamins,
over-the-counter meds DOSE Times per day? Reason/Diagnosis for Medication
_____________________________ ___________ ___________ ____________________________________________
_____________________________ ___________ ___________ ____________________________________________
_____________________________ ___________ ___________ ____________________________________________
_____________________________ ___________ ___________ ____________________________________________
_____________________________ ___________ ___________ ____________________________________________
____________________________ ___________ ___________ ____________________________________________
_____________________________ ___________ ___________ ____________________________________________
CURRENT HEALTH & MEDICAL HISTORY -- ADULT: AGE 19 AND UP Page 2
ALLERGIES
Medication/Food Type of Reaction
_______________________________________ _______________________________________ ( No known allergies
_____________________________ _____________________________
_____________________________ _____________________________
RISK FACTORS
SUBSTANCE RISK FACTORS
Nicotine use? ( Cigarettes (eCigarettes (Cigars (Chew (Nicotine Replacement
( CURRENT ( QUIT ( NEVER
Passive smoke exposure? ( YES ( NO
Alcohol use? ( CURRENT Type_____________ Average # of Drinks ___________ per ( day ( week ( month
( QUIT Date Quit __________
( NEVER
Drug use? ( CURRENT Date of Last Use_________________ Substances used_____________
(Example: marijuana, meth, ( QUIT Date Quit __________ Substances used_____________
Opiates, cocaine, bath salts) ( NEVER
Ever Use IV drugs? ( YES ( NO
SEXUAL HISTORY
Sex at birth? MALE FEMALE OTHER
Gender of current sexual partner(s) MALE FEMALE BOTH NOT ACTIVE
Gender of past sexual partner(s) MALE FEMALE BOTH NEVER BEEN ACTIVE
Number of partners in the past 3 MONTHS?_______ 6 MONTHS?______
Have you ever had an abnormal pap YES NO IF YES, Year______
Have you ever been diagnosed with a STD/STI including HPV? YES NO IF YES, please indicate name of STD_______________________
Have your sexual partners ever used illegal injection drugs? YES NO UNKNOWN
Are you using birth control? YES NO IF YES, METHOD _____________________
(including condoms, vasectomy or tubal ligation)
The CDC recommends a one-time HIV test for everyone age 13-64, and a one-time hepatitis C screening for all Baby Boomers born from 1945-1965. Additional testing may be recommended depending on your medical history and risk factors. Talk to your provider if you want to be tested, or if you want more information about safer sex, birth control, or STDs/STIs.
LIFESTYLE
Caffeine use? ___________ drinks per day
Works with hazardous materials/ chemicals? YES NO
Do you have any tattoos? YES NO
Do you ever feel afraid of your partner YES NO
Do you exercise regularly? YES NO Times per week:_________________ Type of exercise:_______________
Do you regularly use seat belts? YES NO
Guns in the home? YES NO
Sun Exposure? FREQUENTLY OCCASIONALLY RARELY REMOTE
Do you struggle with: ( hearing ( seeing ( making decisions
( climbing stairs ( dressing or bathing ( running errands
HEALTH SCREENING – list the year and location of your most recent:
Annual Exam/Well Child Check _______________________ ________________________________________________________
DATE LOCATION
Colonoscopy _______________________ ________________________________________________________
DATE LOCATION
Pap Test _______________________ ________________________________________________________
DATE LOCATION
Mammogram _______________________ ________________________________________________________
DATE LOCATION
Bone Density or DEXA _______________________ ________________________________________________________
DATE LOCATION
Vaccines _______________________ ________________________________________________________
DATE LOCATION
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Last revised: 7/2018
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