Comprehensive Adult Established Patient Health History Update Questionnaire Form
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Name
Date
Comprehensive Adult Established Patient Health History Update Questionnaire
This is an update form to let us know of any care given by other providers and any changes in your health or status since your last
screening exam. Please fill out both pages. If you are uncomfortable with any question do not answer it. Thank-you!
Main reason for today’s visit: Preventative Visit (Health Maintenance Exam)
Other concerns: ____________________________________________________________________________________________
What are your health goals for the next year? ____________________________________________________________________
How would you rate your health? (circle one): Excellent /
Good /
Fair /
Poor
Please list healthcare providers & their specialty that you see regularly: _____________________________________________
____________________________________________________________________________________________________________
MEDICAL/SURGICAL HISTORY: Any major medical illnesses or surgeries since your last screening exam at our clinic?
□ NO
(List here): __________________________________________________________________________________________________
FAMILY HISTORY UPDATE: Any NEW medical illnesses or deaths in your immediate family since your last screening visit? □ NO
(List here): __________________________________________________________________________________________________
HEALTH ISSUES:
Sexual Activity:
Tobacco Use:
□ Never Are you sexually involved:
□ Not currently □ Never □ Yes
Smoke or smoked cigarettes/ pipe/ cigars (circle)?
□ Yes
Sexual partner(s) is/are/have been/may be in future:
□ male □ female
Exposure to second hand smoke?
□ No
□ Yes
Birth control method or STD prevention (check all that apply):
(If never used any tobacco can skip to Alcohol Use section below)
□ None needed □ Condom □ Pill □ IUD □ Patch □ Ring
□ Diaphragm □ Vasectomy □ Tubal ligation
Current smoker: Packs/day: _________ # of years: _________
□ Other method
Former smoker:
Quit date: __________
(specify):____________________________________________
Approximately how many packs/day did you smoke? _______
Other (ADL):
How many years did you smoke? ________
Military Service?
□ No
□ Yes
Other tobacco?
(circle) Snuff or
Chew
Blood Transfusion?
□ No
□ Yes
Quit date ________
Currently use?
□ Yes
Exposure to toxic chemicals at work?
□ No
□ Yes
Exposure to toxic chemicals doing hobbies?
□ No
□ Yes
Are you ready to quit?
□ No
□ Yes
Diet:
Alcohol Use:
Do you follow a special diet?
□ No □ Yes
Do you drink alcohol?
□ No
□ Yes
(circle) vegetarian, vegan, gluten free,
other
__________________
# of drinks/week: ___________ □ Beer
□ Wine
□ Liquor
Exercise: Do you exercise regularly?
□ Yes □ No
How many times in a year have you had >3 drinks (for women)
If yes, what kind of exercise? ______________________________
>4 drinks (for men) in a day?
___________
______________________________________________________
Drug Use:
How long (minutes)? _____________ How often? ______________
Do you use a helmet for recreational activities?
Have you ever used recreational drugs?
□ No □ Yes
(e.g. bike, skateboard, ski)
□ Not applicable
□ Yes □ No
If yes, which ones? __________________________________
Quit which ones? □ All _______________________________
Do you use seatbelts consistently?
□ Yes □ No
Any used currently? _________________________________
In the past 2 weeks: Have you been feeling down, depressed or
hopeless?
□ No □ Yes
Please continue to next column on right
Do you have little interest or pleasure in doing things?□ No □ Yes
please go to next page
Revised
Page 1 of 2
7/10/2015
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Parent category: Life