Primary Health Solutions-Adult History Form June 2009
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1PRIMARY HEALTH SOLUTIONS
HEALTH HISTORY – ADULT
DATE COMPLETED:
PATIENT NAME:
Date of Birth:
Please complete this form to help us give you the best possible care
Check conditions below that YOU have now
Allergies:
or have had in the past.
Alcoholism/drug addiction
High blood pressure
Current Medications: Include prescription, vitamins and
over the counter / herbal preparations.
Anemia
Kidney disease
Arthritis
Lung disease
Asthma
Mental health problems
Bleeding disorder
Migraines
Blood clot in leg or lung
Rheumatic fever
Cancer ____________
Sexually transmitted infection
Depression
Stomach problems
Diabetes – type: _____
Stroke
Last Tetanus
Epilepsy /Seizures
Tuberculosis
WOMEN’s Health: First menstrual period – Age:_____
Genital discharge / pain
Thyroid __________
Last menstrual period – date: ____/____/____
Heart Disease / Attack
Ulcer
Hepatitis – type: _____
Menopause – year: _________
Urinary problems / pain
OB History: Pregnancies:_____ Living Children:______
Hospitalization, surgery, serious injuries
year
Miscarriages/ Abortions:_________
Birth control:
none
pills Other: ___________________
Last mammogram:__________
Normal
Abnormal
Do you perform Breast Self Exam?
Yes
No
Last pap smear: ___________
Normal
Abnormal
MEN’s Health:
Last prostate exam: __________
Do you perform Self Testicular Exams?
Yes
No
FAMILY HISTORY
Relationship status:
Single
Spouse/partner
Widowed
Check if any family members have had any of the
Education (last grade/degree completed): __________________
following. Write relationship to you in the space.
Your occupation: _____________________________________
Alcoholism, drug addiction
Do you feel physically and emotionally safe in your
Cancer – type:
relationship and your home?
Yes
No
Depression
Do you have financial concerns?
No
Yes
Yes – activity: ________________
Do you exercise?
No
Heart disease
How often? ___________________________
High blood pressure
Alcohol
No
Yes type: ___________ frequency:_______
Lung disease (emphysema/TB)
Drugs
No
Yes type: ___________ frequency:_______
Stroke
Tobacco
No
Yes # per day:_______ since:___________
Diabetes
If yes, would you like help quitting?
No
Yes
NUTRITION
Last exam
Provider
month/year
Special diet: ___________________________________
Medical
Significant weight change in the past 6 months?
No
Yes - ________ lbs.
gain
loss
Dental
Do you get enough to eat?
Yes
No
Eye
Do you have problems with chewing or swallowing?
Hearing
No
Yes - describe:_____________________________
Colon Screening
Completed by: _________________________________
Patient
Other: ___________________________________
Nurse Review: _________________________________
Provider review: ________________________________
ADULT HISTORY FORM 6/09
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