Adult Patient History Form
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2OFFICE USE ONLY
MRN: ________________
MOUNT CARMEL
Medical Group
ADULT PATIENT HISTORY FORM
Welcome to our practice! As a NEW PATIENT, we ask that you fill out this form (both pages) and complete all areas to
the best of your knowledge. This will help us get to know you better and target any issues or concerns you may have.
As a RETURNING PATIENT, we ask that you fill out both pages and complete all areas to the best of your
knowledge. This will help us to review your medical history and update us on any changes over the last year.
Name: ________________________________________ Birth Date: _______________ Date: ____________________
Marital Status: ___________________ Name of Spouse/Significant Other: ____________________________________
Children (with ages): ________________________________________________________________________________
Education: ___________________________________ Occupation: __________________________________________
Do you smoke (currently or in the past)? Y N
If yes, how much? __________________ For how long? ____________
Do you drink any alcoholic beverages? Y N If yes, how many days per week? ________ How many per day? ________
Do you exercise regularly? Y N ______________________________________________________________________
Do you have a living will? Y N
Do you have a power of attorney? Y N
Past Medical History: Please list any medical conditions for which you have been treated in the past.
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Past Surgical History: Please list below any operations with the date.
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Immunizations: Please list the date of your most recent immunizations
Hepatitis A __________
Hepatitis B __________
Flu Shot __________
MMR __________
Pneumonia __________
Tetanus __________
Chicken Pox _______
Meningitis ____________
HPV___________
Shingles ___________
Other ____________________________________
Medications: Please list all of the medications you are taking, including over the counter medications and herbal
supplements. Please include dose and frequency.
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Allergies: Please list all medications you are allergic to and what occurs when you take that medication.
If you have no known allergies, check this box:
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