Adult Health History Form printable pdf download

Adult Health History Form

HIGHLAND FAMILY MEDICINE

ADULT HEALTH HISTORY

PLEASE PRINT CLEARLY OR TYPE

DATE______________

Chart Number________________

Name: __________________

Male_____ Female_____

Birth Date ___________

Birthplace_________________

Address: ______________________________ Home Phone______________ Cell/Other_______________

Education: Highest level of school completed: Elementary___ High School ___ College ___ Other_________

Occupation: ______________________________________________________________

How would you rate your overall health and well-being? Excellent ___ Good ___ Fair ___ Poor ___

What are your major health concerns?

___________________________________________________________

HEALTH FACTORS

1. Do you use tobacco now?

YES ____ NO ____

_____ #cigarettes per day

_____ #pipes/cigars per day

_____ #chewing/smokless tobacco per day

2. If you do not now use tobacco, have you ever used tobacco?

YES ____ NO ____

3. Do you regularly eat? Breakfast ____ Lunch ____ Dinner ____ Snacks/Fluids ____

4. Do you consider yourself? Correct weight ____ Underweight ____ Over weight ____

5. Do you drink caffeinated beverages?

YES ____ NO ____

(Example: coffee, tea, colas, other sodas)

6. Are you on a special diet?

YES ____ NO ____

Explain: ________________________________________________

7. Do you exercise regularly?

YES ____ NO ____

How often? _____________ What type of exercise? ______________

8. Has drinking or drugs ever caused you a problem?

YES ___ NO ____

(Health, legal, driving, family, or work)

9. Do you wear a seatbelt when you drive? Always ____ Usually ____ Occasionally ____ Never ____

10. Has your job or hobby ever involved exposure to a large amount of: paints, varnishes, chemical

solvents, loud noise, asbestos, fiberglass, gasoline powered tools or motors, pesticides, cleaning fluids,

soldering, or radiation?

(If yes, please circle the appropriate agent)

YES ____ NO____

Adult Health History Form