Adult Annual Health History Form Page 2
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2ANNUAL HEALTH HISTORY PAGE 2
Medications and dosages:
Allergies:
1.
2.
3.
4.
Hospitalizations:
5.
1.
2.
6.
3.
4.
7.
5.
6.
8.
Surgeries:
Injuries:
Immunization - When did you last have? (mm/yyyy)
Immunizations: Tetanus
Pneumonia
Flu
TB
Hepatitis B
Other ________
Family History (Circle check mark if cause of death.)
Father
Mother
Brothers
Sisters
Social History
Marital Status:
Single
Married
Divorced
Widowed
Separated Spouse’s Name: ____________________________
Living arrangements
Alone
Family/Significant Other
Assisted Living
Daily help needed for self care
Name of care giver ______________________ Children: How many? _______ Ages: _________________
Occupation: _______________________
FT
PT
Self
Retired from:____________
Activities of Daily Living:
Level of Education:
HS / GED
Tech / A.A
B.S. / B.A. or higher
Any difficulty with?
Diet:
Unrestricted
Low fat
Low carb / diabetic Caffeine:
No
Yes Type/Amt: ______
Speech/Communication
Memory
Dressing
Sleep: # of hours per night _______ Problems: Falling / Staying asleep?
No
Yes
Bathing
Household Duties
Exercise:
No
Yes Type: ___________
Once a week
2-3x/wk
Daily
Fall Risk: Do you have concerns about falling?
No
Yes Do you use any balance/mobility devices? ___________________________
Learning Needs: Are there any needs (learning, ethnic, cultural, or spiritual) we should know about that might impact your care or your
ability to understand treatments / procedures/ educational materials?
No
Yes Please explain: ________________________________
_________________________________________________________________________________________________________________
Abuse / Neglect: Are you experiencing neglect and/or conflict in your family and/or relationships?
No
Past
Current
Tobacco:
Never
Past
Current
Alcohol:
Never
Past
Current
Street Drugs:
Never
Past
Current
What? ________________
Started: __________ Quit: _________
_____ # of drinks per
Day
Week
Started: __________ Quit: _________
Packs per day? ______
Smoke
Chew
Month
Place patient sticker here or handwrite
Name: ___________________________
Left Top/AHH
DOB: ____________________________
Rev 05-04-2011
Form 0002
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Parent category: Medical