Adult Health History Form For New Patients
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4Name_____________________________ Date__________
Date of Birth_____________ Place of Birth______________
E-mail Address________________-____________________
Preferred Method of Communication__________________
Adult Health History for NEW Patients
Main reason for today’s visit: ________________________________________________________________
What are your health goals for the next year? __________________________________________________
Where were you receiving your care before? ___________________________________________________
:
REVIEW OF SYMPTOMS
Please mark the box and/or circle any persistent symptoms you have had in the past few months.
Read through every section and check “no problems: if none of the symptoms apply to you. List other concerns above.
General:
Respiratory:
Genitourinary:
Neurological:
__Fever/ chills
__Shortness of Breath
__Leaking Urine
__Headache
__Night sweats
__Cough
__Blood in Urine
__Memory loss/confusion
__Unexplained weakness
__Wheezing
__Nighttime Urination
__Fainting
__Excessive fatigue
__Loud Snoring
__Urinating More Often
__Dizziness
__Decreased activity
__Short of breath – exercise
__Discharge: Penis or Vagina
__Numbness/Tingling
__Unexplained weight loss/ gain
__Short of breath – lying down
__Concerns w/ Sexual Function
__Unsteady Gait
__No Problems
__Coughing up Blood
__Testicular Pain/lumps
__Frequent Falls
__Coughing up Phlegm
__No Problems
__Tremors
Eye:
__No Problems
__Seizures
__Eye Mattering/Discharge
Musculoskeletal:
__No Problems
__Blindness
Cardiovascular:
__Back Pain
__Blurred/Double Vision
__Chest Pain/Discomfort
__Neck Pain
Psychiatric:
__Glasses/Contact Lenses
__Heart Palpitations
__Muscle Aches/Cramps
__Anxiety/Stress/Irritability
__No Problems
__Swelling in legs/feet
__Joint Pain
__Sleep Problems
__No Problems
__Muscle Weakness
__Lack of Concentration
Ear/Nose/Throat:
__Decreased Joint Motion
__Change in Behavior
__Nose Bleeds
Gastrointestinal:
__Joint Stiffness
__Change in Personality
__Nasal Congestion
__Nausea/Vomiting
__No Problems
__Anorexia
__Sore Throat/Hoarseness
__Diarrhea
__Binging/Purging
__Trouble Swallowing
__Blood in Stools
Hematologic/Lymphatic:
__No Problems
__Hearing loss
__Hemorrhoids
__Bruise Easily
__Ear pain
__Constipation
__Bleeding Tendency
Women Only:
__Dental cavities
__Abdominal Pain
__Swollen glands
__Pre-Menstrual Symptoms
__No Problems
__Heartburn/Reflux
__No Problems
__Excessive/Irregular Bleeding
__Indigestion
__Hot Flashes/Night Sweats
Skin:
__Bloating
Endocrine:
__No Problems
__Rash
__Loss of bowel control
__Heat Sensitivity
__Itching
__Problems eating
__Cold Sensitivity
Breasts:
__New Change in mole
__Loss of appetite
__Excessive Thirst
__Breast Lump/Pain
__Hair Loss/Change
__Excessive gas
__Excessive Hunger
__Nipple Pain
__Change in nails
__Rectal Pain
__High/Low blood sugar
__Nipple discharge
__No Problems
__No Problems
__No Problems
__No Problems
More than Half
Nearly Every
Over the past 2 weeks, how often have you been
Not at all
Several Days
the days
Day
bothered by any of the following problems?
1.
Little interest or pleasure in doing things
0
1
2
3
2.
Feeling down, depressed or hopeless
0
1
2
3
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0 votes
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Parent category: Medical