Adult Annual Health History Form
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1
2Complete
both pages
Today's date:
ANNUAL HEALTH HISTORY
Name:
Age:
Date of last physical exam:
Symptoms: Do you have any of the following?
GENERAL CONSTITUTION
Nose
GASTROINTESTINAL
HEMATOLOGIC &
__ Appetite decreased
__ Hayfever
__ Bloating
ALLERGIES LYMPHATIC
__ Appetite increased
__ Sinusitus
__ Bowel changes
__ Allergic disorders
__ Chills/Rigors
__ Other:
__ Colitis
__ Bleeding disorders
__ Dizziness
Throat & Mouth
__ Constipation
__ Cancer
MEN Only
__ Fainting
__ Hoarseness
__ Diarrhea
__ Swollen glands
__ Breast lump
__ Fatigue/Malaise
__ Mouth sores
__ Difficulty swallowing
__ Other:
__ Erection difficulties
__ Fever
__ Teeth or gum problems
__ Excess belching
__ Lump in testicles
__ Sleeping
__ Other:
__ Gas
MUSCULOSKELETAL
__ Penis discharge
Date of last dental exam:
__ Heartburn
Pain, stiffness, swelling in:
__ Prostate problems
difficulties / Insomnia
__ Swollen glands
__ Hemorrhoids
__ Arms
__ Hips
__ Sore/warts on penis
__ Weight gain, unplanned
__ Hiatal Hernia
__ Back
__ Legs
Date of last PSA:
__ Weight loss, unplanned
RESPIRATORY
__ Indigestion
__ Feet
__ Neck
__ Other:
__ Chronic lung problems
__ Nausea
__ Hands
__ Shoulders
WOMEN Only
__ Coughing blood
__ Nervousness
__ Difficulty with balance
__ Abnormal menstrual periods
HEENT
__ Frequent cough
__ Pancreatitis
__ Difficulty with walking
__ Abnormal Pap smear
Head
__ Shortness of breath
__ Rectal bleeding
Date of last fall:
__ Bleeding between periods
__ Headache
__ Sleep apnea
__ Stomach pain
__ Breast Lumps
__ Neck lumps/swelling
__ Wheezing
__ Stools black or tarry
SKIN
__ Extreme menstrual pain
__ Other:
__ Other:
__ vomiting
__ Bleed or bruise easily
__ Hot flashes
Eyes
Date of last CXR:
__ Vomiting blood
__ Change in mole
__ Painful intercourse
__ Blurred vision
__ Other:
__ Hives
__ Vaginal discharge or itching
__ Double vision
CARDIOVASCULAR
Date of Colonoscopy:
__ Itching
__ Other:
__ Eye changes
__ Artificial heart valves
__ Rash
Date of last period:
__ Other:
__ Chest pains
__ Skin changes
Date of last Pap smear:
Date of last eye exam:
__ History of blood transfer
GENITOURINARY
__ Other:
Date of last mammogram:
__ Irregular / rapid
__ Blood in urine
NEUROLOGIC &
Ears
__ Difficulty urination
Are you pregnant?
heartbeat
__ Earache
__ Poor circulation
__ Frequent urination
No / Yes
PSYCHIATRIC
__ Hearing loss / Difficulty
__ Swelling of ankles or feet __ Kidney/bladder problems
__ Depression or anxiety
Birth control?
No / Yes
__ Other:
__ Varicose veins
__ Lack of bladder control
__ Forgetfulness
__ Other:
__ Other:
__ Numbness
Date of last EKG:
__ Weakness
__ Other:
CONDITIONS: Check conditions you have or have had in the past
List doctors who currently treat you and the conditions treated:
__ AIDS
__ Crohn's
__ Multiple sclerosis
__ Alcoholism
__ Goiter
__ Mumps
__ Anemia
__ Gonorrhea
__ Pacemaker
__ Anorexia
__ Gout
__ Pneumonia
__ Appendicitis
__ Heart attack
__ Polio
__ Arthritis
__ Heart disease
__ Prostate problems
__ Asthma
__ Heart problems
__ Psychiatric care
Patient and Provider need to Date/Time/Initial
__ Bleeding
__ Hepatitis
__ Rheumatic fever
Initial review by Provider:
/
/
disorder
__ Hernia
__ Scarlet Fever
Date
/ Time / Initial
__ Breast lump
__ Herpes
__ Stomach ulcers
/
/
/
/
__ Bronchitis
__ High blood
__ Stroke
Date
/ Time / Initial
Date
/ Time / Initial
__ Bulimia
pressure
__ Suicide attempt
/
/
/
/
__ Cancer
__ High cholesterol
__ Thyroid
Date
/ Time / Initial
Date
/ Time / Initial
__ Chemical
__ HIV positive
problems
/
/
/
/
dependency
__ Kidney disease
__ Tonsillitis
Date
/ Time / Initial
Date
/ Time / Initial
__ Chicken pox
__ Liver disease
__ Tuberculosis
/
/
/
/
__ Diabetes
__ Measles
__ Typhoid fever
Date
/ Time / Initial
Date
/ Time / Initial
__ Migraine
__ Emphysema
__ Vaginal
People assisting with paperwork:
__ Epilepsy
headaches
discharge
__ Glaucoma
__ Miscarriage
__ Vaginal disease
__ Colon cancer
__ Mononucleosis
Interpreter's Name
Interpreter's Signature and/or ID #
Date / Time
Place Patient Sticker here or handwrite
Name: _______________________________
Office Staff Name
Office Staff Signature
Date / Time
DOB: _______________________________
Top Left/AHH
Rev 05-04-2011
Form 0002
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