Adult Health History Form (Page 3 of 4) in pdf

Adult Health History Form Page 3

Previous Now

Now

Bowel problems

Other sexually transmitted disease

Hepatitis or Liver problems

Depression or anxiety

Ulcer

Drug addiction

Gall Bladder disease

Mental health problems

Headaches

Work related disabilities

Back pain

Cancer

Gout

HIV infection

Epilepsy

Blood transfusion

17. Please check the symptoms which you have had during the past year and symptoms which are of

concern to you now.

Previous Now

Now

Skin lump, rash or sores

Loss of consciousness

Mole change (color or size)

Loss of balance/falls

Eye problems

Speech difficulties

Dental or denture problems

Back pain

Hoarseness

Shortness of breath

Excessive thirst or appetite

Chest pain

Coughing or vomiting blood

Swollen ankles

Wheezing

Weight change

Chronic cough

Difficulty sleeping

Irregular heartbeat

Excessive tiredness

Leg pain with exertion/or rest

Loss of appetite

Difficulty swallowing

Unusual bleeding or bruising

Feelings of tension or unhappiness

Heartburn

Nausea or vomiting

Difficulty concentrating

Diarrhea or constipation

Problems with sexual functions

Black or bloody stool

Problems with infertility

Hemorrhoids

For men: sores or discharge from

penis

Changes in bowel habits

Pain or swelling in testicles

Difficulty urinating

For women: unexpected vaginal

bleeding

Cloudy or bloody urine

Vaginal discharge

Joint or muscle pain

Hot flashes

Dizziness

Pain or lump in breast

Weakness or paralysis

Discharge from nipples

Tingling or numbness

Difficulty with menstrual period

Frequent or severe headaches

18. MEDICATIONS

Please list the names of all medications that you now take:

_______________________________________________________________________________

Adult Health History Form Page 3

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