Adult Health History Form Page 4
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419. FAMILY HISTORY
Check and indicate which family member(s) has or had the following health problems:
(Mother, Father, Brother, Sister, Aunt, Uncle, Grandparent)
_____ Bleeding tendency
_____ Glaucoma
_____ Mental illness
_____ Birth defects
_____ Cancer
_____ Kidney disease
_____ Stroke
_____ Emphysema
_____ Alzheimer’s
_____ Miscarriage
_____ High Blood Pressure
_____ Alcohol or Drug addiction
_____ Cholesterol
_____ Tuberculosis
_____ DES (mother)
_____ Diabetes (sugar)
_____ Heart Disease
other family health problems: _______________________
20. Please list family members: parent(s), brother(s), sister(s), spouse, children, and their current health.
Name
Relationship
If alive, indicate health:
If dead, indicate age
good-poor
and cause of death
21. Do you live with others?
YES _____ NO _____
Describe with whom? ____________________________________
OTHER HEALTH PROBLEMS
22. Please list other health care professionals seen within the last 3-5 years.
Physician, Dentist, or Therapist Name and Address
Specialty
Last Visit
TOPICS YOU WISH TO DISCUSS
23. Check the items you would like to discuss with your health care provider:
_____ Family
_____ Services for elderly
_____ Work
_____ Living Will/Health Care Proxy
_____ Exercise
_____ Grieving
_____ Birth Control
_____ Anxiety
_____ Parenting
_____ Smoking
_____ Retirement
_____ Osteoporosis
_____ Stress
_____ HIV/Aids
_____ Sexual function
_____ Diet/food intake
_____ Depression
_____ Emotional Control
_____ Infertility
_____ Premenstrual Syndrome
_____ Alcohol use
_____ Sexually transmitted diseases
_____ Anger
_____ Cancer signs
Other: _______________________________________________________________
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Parent category: Medical