Adult Patient Packet - Community Quick Care Page 2
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3Adult History Questionnaire
Patient Name: ______________________________________________________________________________________________
Date of Birth: _____/_____/_____
Age: _______
M / F________
Medications
Please list all medications below:
Dosage
Frequency
Reason for Medication
Name of medication
General
_____
_____
: _________________________________________________
Do you consider yourself to be in good health?
Yes
No Explain
_____
_____
: ________________________________________________
Do you have a serious illness or medical condition?
Yes
No Explain
? _____
_____
________________________________________________
Have you had any serious injuries or accidents
Yes
No Explain:
_____
_____
______________________________________________________________
Have you had any surgeries?
Yes
No Explain:
_____
_____
___________________________________________________________
Have you ever been hospitalized?
Yes
No Explain:
_____
_____
: ______________________________________________________
Are you allergic to any medicines or drugs?
Yes
No Explain
Family History
Have any family members had the following:
Deafness:
_____ Yes
_____ No
Who ______________ Comments _________________________________
Nasal Allergies
_____ Yes
_____ No
Who ______________ Comments _________________________________
Asthma
_____ Yes
_____ No
Who ______________ Comments _________________________________
Tuberculosis
_____ Yes
_____ No
Who ______________ Comments _________________________________
Heart Disease (before 50 years old)
_____ Yes
_____ No
Who ______________ Comments _________________________________
High Blood Pressure (before 50 years old)
_____ Yes
_____ No
Who ______________ Comments _________________________________
High Cholesterol
_____ Yes
_____ No
Who ______________ Comments _________________________________
Anemia
_____ Yes
_____ No
Who ______________ Comments _________________________________
Bleeding disorder
_____ Yes
_____ No
Who ______________ Comments _________________________________
Liver Disease
_____ Yes
_____ No
Who ______________ Comments _________________________________
Kidney Disease
_____ Yes
_____ No
Who ______________ Comments _________________________________
Diabetes (before 50 years old)
_____ Yes
_____ No
Who ______________ Comments _________________________________
Epilepsy or convulsions
_____ Yes
_____ No
Who ______________ Comments _________________________________
Alcohol abuse
_____ Yes
_____ No
Who ______________ Comments _________________________________
Drug Abuse
_____ Yes
_____ No
Who ______________ Comments _________________________________
Mental Illness
_____ Yes
_____ No
Who ______________ Comments _________________________________
Mental Retardation
_____ Yes
_____ No
Who ______________ Comments _________________________________
Immune Problems, HIV, or AIDS
_____ Yes
_____ No
Who ______________ Comments _________________________________
Cancer
_____ Yes
_____ No
Who ______________ Comments _________________________________
Sickle Cell Disease
_____ Yes
_____ No
Who ______________ Comments _________________________________
Additional family history _______________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
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Parent category: Medical