Adult Health History Form For New Patients (Page 4 of 4) in pdf

SOCIAL HISTORY:

TOBACCO USE:

EXERCISE:

Smoke cigarettes: [ ]NEVER [ ] NO [ ] YES

Do you exercise regularly?

[ ] Yes [ ] No

Other tobacco: [ ] Pipe [ ] Cigar [ ] Snuff [ ] Chew

What kind of exercise? ______________________

Current smoker: Packs/day______ # of years: ________

How many minutes? _______________

Quit Date: ________

How often?______________________

How many years did you smoke? ___

How many packs a day did you smoke? ________

DIET:

Are you following a special diet?

[ ] No [ ] Yes

Type: _______________

ALCOHOL USE:

Do you drink alcohol?

[ ] No

[ ] Yes

Would you like help with your diet?

[ ] No [ ]Yes

# of drinks per week: ________ [ ] Beer [ ] Wine [ ] Liquor

SAFETY:

Do you use seatbelts consistently?

[ ] Yes [ ] No

DRUG USE:

Do you use recreational drugs? [ ] No [ ] Yes

Home has a working smoke detector? [ ] Yes [ ] No

Use needles to inject drugs?

[ ] No [ ] Yes

Is violence at home a concern for you? [ ] Yes [ ] No

Abuse Prescription drugs?

[ ] No [ ] Yes

WOMEN’S HEALTH HISTORY:

SEXUAL ACTIVITY:

Total number of pregnancies: ______________

Sexually involved currently: [ ] No

[ ] Yes

Number of births: ______________

Birth control: [ ] None [ ] Condom [ ] Pill [ ] Diaphragm

Date of last menstrual period: ____________________

[ ] Other:_________________

Age at beginning of periods (menstruation):_________

Age at end of periods (menopause): _______________

EMPLOYMENT/PERSONAL:

Occupation (or prior occupation): ____________________

EDUCATION:

[ ]Retired [ ]Unemployed [ ]Leave of Absence [ ]Disabled

High School Graduate? [ ] Yes [ ] No [ ] GED

Employer: _____________________________________

Highest Educational Level: ____________________________

Marital Status [ ] Single

[ ] Married

[ ] Divorced

IMMUNIZATIONS:

[ ] Partner [ ] Widowed

Spouses/Partners Name: __________________________

Check this box if you don’t know the information [ ]

Number of Children & Ages: ________________________

Please check off any vaccinations. Add year, if known.

Number of Grandchildren:__________________________

Tetanus (Td)__________

Pneumovax (pneumonia)___________

Who lives at home with you? _______________________

Varicella (Chicken Pox) shot or illness _____________

Hepatitis A ______________

Hepatitis B______________

HEALTH MAINTENANCE SCREENING TESTS:

Mammogram (Women Only): Date_______________

MMR___________________

Pap Smear (Women Only): Date__________________

Meningitis______________

Bone Density Test (Women Only): Date____________

Zostavax (shingles) ____________

Lipid (cholesterol) Screening: Date________________

HPV ______________

Colonoscopy or Sigmoidoscopy: Date______________

Influenza (flu shot)_______________

Thank you for taking the time to fill out this important health documentation.

Adult Health History Form For New Patients Page 4

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