ADULT HISTORY
Please complete this form and
bring it with you to your visit.
IHA PRIMARY CARE
PLEASE BRING ALL MEDICATION(S) TO YOUR APPOINTMENT.
Date: ____________________________
Name: ____________________________________________________________________________
Date of Birth: _______________________
(Last)
(First)
(Middle)
Male Female Other
Single Married Widow(er) Partner Divorced
Who do you live with? Alone Partner Family Other
Occupation: _________________________________________________
Emergency Contact Name:________________________________ Emergency Contact Phone: _________________________________________
Do you take your medications as directed? Yes No
Routine Check Up — No Symptoms
*Please bring all medications to your visit in a bag.
Name of Medication
Dosage
Times Per Day
Reason for Visit: (please list all current symptoms)
1. _____________________________________________________
1. _____________________________________________________
2. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
3. _____________________________________________________
4. _____________________________________________________
Chronic Problems:
5. _____________________________________________________
1. _____________________________________________________
6. _____________________________________________________
2. _____________________________________________________
7. _____________________________________________________
3. _____________________________________________________
8. _____________________________________________________
4. _____________________________________________________
9. _____________________________________________________
5. _____________________________________________________
10. ____________________________________________________
6. _____________________________________________________
7. _____________________________________________________
Supplements / Herbs / Over the counter medication:
8. _____________________________________________________
1. _____________________________________________________
2. _____________________________________________________
Allergies:
o S
r u
e c
R
a e
t c
o i
n
FOR WOMEN ONLY
1. _____________________________________________________
How many: Pregnancies
__________
Live births __________
2. _____________________________________________________
Menstrual History:
3. _____________________________________________________
Age when menstrual period began
____________
4. _____________________________________________________
Do you use any form of birth control? Yes No
5. _____________________________________________________
If yes, what? ______________________________________________
6. _____________________________________________________
First day of last menstrual period ____________________________