Adult History And Review Of Systems Questionnaire Page 2
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3ALLERGIES and Bad Reactions to Medications:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
MEDICATIONS:
Name
Dosage
Times a day
1.
___________________________________________________________________________________________________
2.
___________________________________________________________________________________________________
3.
___________________________________________________________________________________________________
4.
___________________________________________________________________________________________________
5.
___________________________________________________________________________________________________
6.
___________________________________________________________________________________________________
7.
___________________________________________________________________________________________________
8.
___________________________________________________________________________________________________
9.
___________________________________________________________________________________________________
10.
___________________________________________________________________________________________________
Has anyone in your FAMILY ever had? (If yes check box and list relationship)
Cancer & Type
_______
Dialysis
_______
Crohn’s/colitis
_______
Diabetes
_______
Chronic lung disease
_______
Alzheimer’s
_______
Cardiac Dysrhymthia
_______
Tuberculosis
_______
Alcoholism
_______
Congestive Heart Failure_______
Rheumatoid Arthritis
_______
Bleeding tendency
_______
Coronary Artery Disease_______
Thyroid trouble
_______
Anemia
_______
Valvular heart Disease _______
Osteoporosis
_______
Gout
_______
High Blood Pressure
_______
Cystic Fibrosis
_______
Depression
_______
High Cholesterol
_______
Asthma
_______
Mental illness
_______
Stroke
_______
Peptic Ulcer
_______
Seizures
_______
Kidney stones
_______
Gallstones
_______
Migraine headaches
_______
Kidney disease
_______
OTHER
___________________________________________
GYNECOLOGICAL/ OBSTETRICAL HISTORY:
Name of OB-GYN
________________________________________________
Age when you Started Menstruating?
_______
Number of Pregnancies?
_______
Date of Last PAP?
_______
Number of Births?
_______
History of abnormal Pap’s
Yes / No (Please circle)
Vaginal / C-section
(Please Circle)
Date of Last Mammogram?
_______
Method of Contraception
_____________________
History of Abnormal Mammograms
Yes / No (Please circle)
Menstrual Cycles?
Regular / Irregular (Please Circle)
Pain with Periods?
Yes / No (Please Circle)
Age at Menopause?
_______
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