Adult Health History Form
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1Doctor
Address
Address
Phone
ADULT HEALTH HISTORY
Date
Name
Date of birth
Age
General health
Are you currently or have you ever been treated for
Yes
No
Condition
Explain
Asthma
Bleeding disorders
Blood Pressure
COPD
Diabetes
Ear/sinus
Fainting
Gastro-intestinal problems
Heart disease
Kidney disease
Learning disorders
Menstrual problems
Musculo-skeletal
Psychological/psychiatric
Seizures
Sickle cell disease
Sleep disorders
Stroke
Surgery
Thyroid disease
Serious injury
Other
List all medications you are currently taking, include over-the-counter drugs and herbal
supplements
Medication
Dosage
Reason
Allergies
Signature
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Parent category: Medical