Adult History And Review Of Systems Questionnaire
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3Adult History and Review of Systems Questionnaire
Note: This is a confidential record of your medical history. As your doctors, it is important for us to know this information so we can
provide you with the best health care possible. The information contained here will not be released to anyone without your prior consent.
Name
Date
Date of Birth
Male
Female
SpouseSignificant Other
SOCIAL HISTORY:
Birthplace
Your Occupation
Nationality
Education
Religion
Marital Status
How many years________
Drug Use___________________________________________
Children____________________________________________
Tobacco Use
Yes
No
Type
___________________________________________________
Packs per day
for
years
Quit
Pets
Alcohol Use _______________________________________
Exercise (type/how often?)_______________________________
Drinks _____ per
day
week
month
Recent or Frequent Travel Destinations ___________________
___________________________________________________
If heavy use, how many years
Quit
Caffeine (coffee, tea, soda, chocolate) Servings per day
Have YOU ever had? (IF YES, CHECK APPROPRIATE BOXES)
Cancer Type:______________
Emphysema
Glaucoma
Prostate Enlargement
Heart Attack/Coronary
Pneumonia
Thyroid Trouble
Cystic Fibrosis
Artery Disease
Tuberculosis
Hives
Malaria
Rheumatic Fever
Positive TB Skin Test
Depression
Other________
Heart failure
Osteoporosis
Head Injury
______________
High blood pressure
Arthritis
Broken Bones
High cholesterol
Gout
Blood transfusions
IMMUNIZATIONS:
Stroke
Frequent Bladder Infection
Sexually Transmitted
Measles, Mumps and
Diabetes
Kidney Stones
Diseases: Herpes, HIV,
Rubella Vaccine
Gallstones
Kidney Disease
Gonorrhea, Chlamydia,
Chicken pox vaccine
Liver Disease
Polio
Syphilis
Hepatitis B vaccine
Hepatitis/Jaundice
Chicken Pox
Intravenous drug abuse
Influenza vaccine
Ulcer disease
Infectious Mono
Needle injury
Pneumococcal vaccine
Heartburn / Reflux
Anemia
Mumps
Tetanus booster
Asthma
Frequent Sinus Infections
Migraines
Seizures
PAST SURGICAL HISTORY: If yes, please check the box and enter the year.
Eyes (Laser or Vision
Gall Bladder
_______
Spinal Surgery/Back
_______ __
Corrected)
____
Appendix
_______
Orthopedic (Hips/ Knee _________
Eyes (Cataract/Glaucoma)
____
Intestine/Colon
_______
Shoulder/ Feet/Hands) _________
Ears
____
Hemorrhoids
_______
C-section
_________
Sinus/Nasal Septum
____
_________
Hernia
_______
Tonsils/Adenoid
____
Vasectomy
_________
Breast
_______
Thyroid
____
Tubal Ligation
_________
Uterus/Hysterectomy
_______
Heart
____
Ovaries
_______
Stomach
____
Spinal Surgery/Neck
_______
Varicose Veins
____
Prostate
_______
OTHER ________________________
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