Adult Health History Form - Ut Physicians printable pdf download

ADULT HEALTH HISTORY FORM

Name_________________________________________

Date_______________________________________

DOB___________________ Gender__________ Marital Status____________ Address__________________________________________

Tel #________________________

Emergency Contact______________________________________ Emergency Contact # ________________________ Race/Ethnicity____________ Email_______________________

Language Preference____________________

Patient/family preferred method of communication: English / Spanish

Health Insurance_____________________________

Preferred contact method

Phone

Do you have vision or hearing impairment? (circle if any)

Vision

Hearing

How would you rate your general health?

Excellent

Good

Fair

Poor

Main reasons/concerns for today's visit?___________________________________________________________________________________________________________________

REVIEW OF SYMPTOMS: Please check any current symptoms you have:

Constitutional

Respiratory

Skin

___ Recent fevers/sweats

___ Cough/wheeze

___ Rash

___ Unexplained weight loss/gain

___ Coughing up blood

___ New or change in mole

___ Unexplained fatigue/weakness

Gastrointestinal

Neurological

Eyes

___ Heartburn/reflux

___ Headaches

___ Change in vision

___ Blood or change in bowel movement

___ Memory loss

___ Nausea/vomiting/diarrhea

___ Fainting

Ears/Nose/Throat/Mouth

___ Difficulty hearing/ringing in ears

Genitourinary

Psychiatric

___ Hay fever/allergies/congestion

___ Painful/bloody urination

___ Anxiety/stress

___ Trouble swallowing

___ Leaking urine

___ Sleep problem

___ Nighttime urination

Cardiovascular

___ Discharge: penis or vagina

Blood/Lymphatic

___ Chest pains/discomfort

___ Unusual vaginal bleeding

___ Unexplained lumps

___ Palpitations

___ Concern with sexual functions

___ Easy bruising/bleeding

___ Short of breath with exertion

Musculoskeletal

Endo

Breast

___ Muscle/joint/pain

___ Cold/heat intolerance

___ Breast lump

___ Recent back pain

___ Increase thirst/appetite

___ Nipple discharge

In the past month, have you had little interest or pleasure in doing things, or felt down, depressed, or hopeless?

Yes

MEDICATIONS: Prescription and non-prescription medicine, vitamins, home remedies, birth control pills, herbs, etc.

Medication

Dose

How many times per day

______________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Allergies or reactions to medications: _____________________________________________________________________________________________________________________

Date of your most recent IMMUNIZATIONS:

Hepatitis A________________

Hepatitis B________________

Influenza (flu shot)________________

MMR ______________ Pnumovax (pneumonia)_______________________

Meningitis_________________

Tetanus (Td)______________

Varicella (chicken pox) shot or illness______________________ Tdap (tetanus & pertussis)_____________________

HEALTH MAINTENANCE SCREENING TESTS: (PLEASE LEAVE BLANK FOR YOUR NURSE TO COMPLETE)

Lipid (cholesterol)_____________________________________

Date _______________ Abnormal?

Yes