Adult Health History Form



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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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