Detailed Adult History Form
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6DETAILED ADULT HISTORY FORM
The following information is very important to your health. Please take the time to fully complete this form.
Last Name: ______________________________
First Name: __________________________
Birthdate: _______________
Age: _______
Sex:
Male
Female
Occupation: _____________________________
Marital status: ________________________
Information completed by: __________________
Relationship to patient: ________________
Section 1: Immunizations / TB Skin Testing
Have you received immunizations for any for the following?
Tetanus/
Yes
No
Flu
Yes
No
Hepatitis A
Yes
No
Diphtheria
Year ________
Vaccine
Year ________
Vaccine
Year _______
Pneumonia
Yes
No
Hepatitis B
Yes
No
TB Skin test
Pos.
Neg.
Vaccine
Year ________
Vaccine
Year ________
Year _______
Have you traveled outside of the U.S. in the last two years?
Yes
No
Where? _________________________________________
Section 2: Past Medical History
Have you ever been diagnosed or treated for any of the following? (Also, see next page)
AIDS
YES
NO
HERPES
YES
NO
ALLERGIES
YES
NO
HIGH B/P
YES
NO
ANEMIA
YES
NO
HIV POSITIVE
YES
NO
ANXIETY
YES
NO
KIDNEY DISEASE
YES
NO
ARTHRITIS
YES
NO
MENINGITIS
YES
NO
ASTHMA
YES
NO
MEASLES
YES
NO
BLEEDING PROBLEMS
YES
NO
MUMPS
YES
NO
BLOOD CLOTS
YES
NO
NEURO. PROBLEMS
YES
NO
BRONCHITIS
YES
NO
PERTUSSIS
YES
NO
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