Adult Medical History Form printable pdf download

Medical History Form

Your answers on this form will help us understand your medical concerns and conditions better. If you

are uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember

specific details.

Name_________________________________ Date of Birth____________ Today’s date__________

1. Personal Medical History

Please indicate if you have had any of the following problems currently or in the past.

Anemia

 Yes

 No

Kidney disease/stones

 Yes

 No

Arthritis

 Yes

 No

Liver disease/Hepatitis

 Yes

 No

Asthma/Emphysema  Yes

 No

Lung disease/pneumonia

 Yes

 No

Bladder infections

 Yes

 No

Pancreatitis

 Yes

 No

Chronic diarrhea

 Yes

 No

Rheumatic Fever

 Yes

 No

Diverticulosis

 Yes

 No

Skin disease

 Yes

 No

Diabetes

 Yes

 No

Sleep apnea

 Yes

 No

If yes, what age?_____

Stroke

 Yes

 No

Emotional problems  Yes

 No

Venereal disease/Syphilis

 Yes

 No

Epilepsy or Seizures  Yes

 No

Gonorrhea/Chlamydia

 Yes

 No

Gallstones

 Yes

 No

Thyroid disease/Goiter

 Yes

 No

Gout

 Yes

 No

Tuberculosis

 Yes

 No

Heart Disease

 Yes

 No

Tumors/Cancer

 Yes

 No

High Cholesterol

 Yes

 No

Ulcers (stomach or intestinal)  Yes

 No

High Blood Pressure  Yes

 No

Acid Reflux (Heartburn)

 Yes

 No

If yes to any of the above, please explain__________________________________________________

__________________________________________________________________________________

When was your last Tetanus shot given? _____________

2. Family History

 Adopted, family history unknown.

Has anyone in your family (including grandparents, parents, brothers, sisters, or children) had any of

the following conditions?

Family Relationship:

Living/Deceased:

Alcoholism

 Yes

 No

__________________

________________

Anemia

 Yes

 No

__________________

________________

Arthritis

 Yes

 No

__________________

________________

Bowel/Colon Cancer

 Yes

 No

__________________

________________

Breast Cancer

 Yes

 No

__________________

________________

Depression

 Yes

 No

__________________

________________

Diabetes

 Yes

 No

__________________

________________

Heart Disease/Angina

 Yes

 No

__________________

________________

Hepatitis

 Yes

 No

__________________

________________

High Blood Pressure

 Yes

 No

__________________

________________

High Cholesterol

 Yes

 No

__________________

________________

Kidney Disease

 Yes

 No

__________________

________________

Strokes

 Yes

 No

__________________

________________

Thyroid Disorder

 Yes

 No

__________________

________________

Tuberculosis

 Yes

 No

__________________

________________

Other_________________

 Yes

 No

__________________

________________

Adult Medical History Form

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