Adult Patient Packet - Community Quick Care Page 3
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3Adult History Questionnaire Cont:
Patient Name: _____________________________________________________________________________________________
Birth Date: _____/_____/_____
Age: _____
M / F _____
______________________________________________________________________________________________________________________
Past History
Do you have, or ever had:
Chickenpox
_____ Yes
_____ No
When ________________________________________________________
Frequent ear infections
_____ Yes
_____ No
Explain _______________________________________________________
Problems with ears or hearing
_____ Yes
_____ No
Explain _______________________________________________________
Nasal allergies
_____ Yes
_____ No
Explain _______________________________________________________
Problems with eyes or vision
_____ Yes
_____ No
Explain _______________________________________________________
Asthma, bronchitis, or pneumonia
_____ Yes
_____ No
Explain _______________________________________________________
Any heart problem or heart murmur
_____ Yes
_____ No
Explain _______________________________________________________
Anemia or bleeding problem
_____ Yes
_____ No
Explain _______________________________________________________
Blood transfusion
_____ Yes
_____ No
Explain _______________________________________________________
Frequent abdominal pain
_____ Yes
_____ No
Explain _______________________________________________________
Constipation requiring doctors visits
_____ Yes
_____ No
Explain _______________________________________________________
Bladder or kidney infection
_____ Yes
_____ No
Explain _______________________________________________________
Any chronic or recurrent skin problem
_____ Yes
_____ No
Explain _______________________________________________________
(acne, eczema, etc.)
Frequent headaches
_____ Yes
_____ No
Explain _______________________________________________________
Convulsions or other neurologic problem
_____ Yes
_____ No
Explain _______________________________________________________
Diabetes
_____ Yes
_____ No
Explain _______________________________________________________
Thyroid or other endocrine problem
_____ Yes
_____ No
Explain _______________________________________________________
Any other significant problem
_____ Yes
_____ No
Explain _______________________________________________________
Use of alcohol or drugs
_____ Yes
_____ No
Explain _______________________________________________________
Family and Social History
Please circle one for each family member:
Father
Alive
Deceased
Unknown
Mother
Alive
Deceased
Unknown
Siblings
Alive
Deceased
Unknown
N/A
Please circle only one per line:
Water in home
Bottled water
City Water
Well water
Spring Water
Smoking
Yes
No
Details: _____________________
Home Type
Mobile home
Apartment
House
Duplex
Pets at Home
Indoors
Outdoors
None at Home
Home Heat type
Forced Air
Baseboards
Home Mold/Mildew
Yes
No
Alcohol/ Drugs
Yes
No
Details: _____________________
Sexually Active
Yes
No
Traveled outside US
Yes
No
Details: _____________________
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Parent category: Medical