Adult History New Patient Form Page 3
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1
2
3Personal and Family History
Unknown/Adopted
(Check all that apply)
Circle any items that were known cause of death for relative
MEDICAL CONDITION
SELF
RELATIVE
MEDICAL CONDITION
SELF
RELATIVE
ADD/ADHD
Yes No
__________
Irritable bowel disease
Yes No
__________
Alcoholism
Yes No
__________
Kidney disease
Yes No
__________
Allergies
Yes No
__________
Kidney stones
Yes No
__________
Alzheimer's Disease/Dementia
Yes No
__________
Learning disability
Yes No
__________
Anemia
Yes No
__________
Liver disease
Yes No
__________
Angina
Yes No
__________
Lupus
Yes No
__________
Anxiety
Yes No
__________
Mental illness
Yes No
__________
Arthritis
Yes No
__________
Migraines/headaches
Yes No
__________
Asthma
Yes No
__________
Obesity
Yes No
__________
Atrial brillation
Yes No
__________
Osteoarthritis
Yes No
__________
BPH (enlarged prostate)
Yes No
__________
Osteoporosis
Yes No
__________
Blood clots
Yes No
__________
Peptic ulcer disease
Yes No
__________
Blood disease (vists to hematology)
Yes No
__________
Peripheral vascular disease
Yes No
__________
Cancer(s):
Psoriasis
Yes No
__________
Breast
Yes No
__________
Rheumatoid Arthritis
Yes No
__________
Colon
Yes No
__________
Seizure disorder/Epilepsy
Yes No
__________
Lung
Yes No
__________
Thyroid disease
Yes No
__________
Prostate
Yes No
__________
OTHER (please list)
Other:
Yes No
__________
________________________
Yes No
__________
CVA (Stroke or TIA)
Yes No
__________
________________________
Yes No
__________
Colon problems
Yes No
__________
________________________
Yes No
__________
COPD (emphysema)
Yes No
__________
Coronary artery disease
Yes No
__________
Have you had the following illnesses or vaccines?
Depression
Yes No
__________
Check all that apply
Date
Developmental Delay
Yes No
__________
Hepatitis A
__________
Diabetes
Yes No
__________
Hepatitis B
__________
Eczema
Yes No
__________
HPV (Gardasil)
__________
Gall Stones
Yes No
__________
In uenza
__________
Gallbladder disease
Yes No
__________
Last tetanus vaccination
__________
GERD
Yes No
__________
Pneumonia (Pneumovax)
__________
Glaucoma/Cataracts
Yes No
__________
Pneumonia (Prevnar)
__________
Hearing de ciency
Yes No
__________
Shingles shot (Zostavax)
__________
Heart disease/problems
Yes No
__________
before age 40 (male)
Yes No
__________
before age 50 (female)
Yes No
__________
FOR WOMEN ONLY
Hemorrhoids
Yes No
__________
Screening Tests
Date
Hernia
Yes No
__________
Hepatitis C
Yes No
__________
Last pap smear:
__________
Hyperlipidemia (high cholesterol)
Yes No
__________
Any abnormal pap smears?
Hypertension (high blood pressure)
Yes No
__________
Yes No
If yes, indicate results and date.
Injuries:
Concussion or head injury
Yes No
__________
Car/motorcycle accident injury
Yes No
__________
Mammogram:
__________
Ever been knocked unconscious Yes No
__________
Any abnormal mammograms?
Broken bones?
Yes No
__________
Yes No
If yes, indicate results and date.
Which ones?
Any other injuries:
Yes No
__________
REV 3/6/15
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