Detailed Adult History Form Page 5
ADVERTISEMENT
1
2
3
4
5
6Section 9: History of Present Illness/Chief Complaint/Review of Systems
Do you have any of the following signs and symptoms?
ABDOMINAL PAIN
YES
NO
FEVER/CHILLS
YES
NO
BACK PAIN
YES
NO
HEARING PROBLEMS
YES
NO
BLOOD IN NOSE
YES
NO
HEART BEATING FAST
YES
NO
BLOOD IN STOOL/BOWEL
YES
NO
JOINT OR MUSCLE PAIN
YES
NO
BLOOD IN URINE
YES
NO
LOSS OF CONSCIOUSNESS
YES
NO
BREAST MASS/DISCHARGE
YES
NO
NAUSEA OR VOMITING
YES
NO
CHANGE IN SKIN
YES
NO
SHORTNESS OF BREATH
YES
NO
CHEST PAIN
YES
NO
THROAT SORENESS
YES
NO
COUGH
YES
NO
WHEEZING
YES
NO
DIZZINESS
YES
NO
URINARY FREQUENCY/URGENCY
YES
NO
EXCESSIVE SWEATING
YES
NO
URINARY DISCOMFORT
YES
NO
EXCESSIVE THIRST
YES
NO
WEIGHT CHANGE:
UP______ DOWN_____
EYESIGHT CHANGES
YES
NO
AMOUNT OF WEIGHT CHANGE ____________
Section 10: Females
Males: Skip this section, go to the last page and sign.
Menstrual Cycle:
Age at first period
_____ Number of days of menstrual flow ________
Describe menstrual flow
Heavy
Average
Light
Painful
Are/were periods regular?
_____ Have your periods changed? How? _________________________
# Days between periods
_____ Date of last menstrual period ______________________________
Menopause:
Age at menopause:
______
Any bleeding/spotting since menopause?
YES
NO Describe:
_________________________________
Ever taken hormone shots or pills?
YES
NO Describe:
_________________________________
Have you had bone density screening?
YES
NO When?
_________________________________
*A8490125
Page 5 of 6
1/5/11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical