Adult Health History Form For New Patients Page 2
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4MEDICATIONS:
Please list (or show us your own printed record) all prescriptions and non-prescription medications, vitamins, home
remedies, birth control pills, herbs, inhalers, etc… Use the back of this form if you need more room and let us know that you wrote there.
I TAKE NO MEDICATIONS
Please List Your PHARMACY of Choice ________________
MEDICATION
DOSE (mg/pill)
HOW MANY TIMES PER DAY?
ALLERGIES:
Please list all allergies or intolerance to medications: Please include type of reaction:
NO KNOWN ALLERGIES
ALLERGIES:
TYPE OF REACTION:
PERSONAL MEDICAL HISTORY:
Do you have now (current) or have you had in the past any of the following
conditions?
√
CONDITION
COMMENTS
√
CONDITION
COMMENTS
Alcohol/Drug Abuse
Gout
Allergy/Hay Fever
Gyn. Conditions (Endometriosis)
Anemia
Gyn. Conditions (Fibroids)
Anxiety
Hepatitis – Type A/Type B/Type C
Arthritis (Rheumatoid)
High Blood Pressure
Arthritis (Osteoarthritis)
High Cholesterol
Asthma
Inflammatory Bowel Disease
Atrial Fibrillation
Irritable Bowel Syndrome
Bipolar Disorder
Kidney Disease/Failure
Bladder Problems
Kidney Stones
Blood Clot (leg/lung)
Liver Disease
Blood Transfusion
Lupus
Breast Condition (benign)
Migraine/Tension Headaches
Cancer Breast
Osteoporosis
Cancer Colon
Pancreatitis
Cancer Lung
Pneumonia
Cancer Prostate
Prostate Enlargement/Nodules
Cancer (Other type)_________
Seizures/Epilepsy
Cataracts
Skin Condition (Eczema/Psoriasis)
Colon Polyp
Skin Cancer ___________
Coronary Artery Disease/Heart Attack
Sleep Apnea
Depression
Stomach Ulcer
Diabetes (Adult Onset) (Type 2)
Stroke
Diabetes (Childhood Onset) (Type 1)
Overactive Thyroid/Hyperthyroidism
Diverticulosis
Low Thyroid/Hypothyroidism
Emphysema (COPD)
UTI
Fractures (broken bones)__________
Other (list)
Gallbladder Disease
Other (list)
Heartburn/Reflux (GERD)
Other (list)
Glaucoma
Other (list)
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