Adult Medical History Form (Page 2 of 3) in pdf

3. Personal Habits

Tobacco Use

Cigarettes:  Never  Quit-Date______  Current Smoker-Packs per day___ # of years___

Other tobacco:  Pipe

 Cigar

 Snuff

 Chew

Are you interested in quitting?

 Yes

 No

Alcohol Use

Do you drink alcohol?

 No

 Yes, average # of drinks per week_____

If no, have you in the past?

 Yes

 No

Drug Use

Do you use any recreational drugs, such as marijuana, cocaine, stimulants, narcotics, diet pills?

 Yes

 No

Have you ever used needles?

 Yes

 No.

Sexuality

Are you sexually active?

 Yes

 No

 Not currently

If sexually active, do you practice safe sex?  Yes

 No

Birth control method________________

Have you ever had any sexually transmitted diseases (STD's)?  Yes

 No

If yes, please include___________________________________________________________

Exercise

Do you exercise regularly?

 Yes

 No

If yes, what type of exercises?____________________________________________________

Emotions

In the past year, have you had 2 weeks or more during which you felt sad, blue, or depressed;

or when you lost interest or pleasure in things that you usually enjoyed?

 Yes

 No

4. Medications

Please list all your current medications, including medications/supplements not needing a prescription:

Medication

Dose and Directions

___________________________________ ______________________________________________

5. Allergies

Please list any allergies or reactions to medications:

Medication

Reaction or Side Effect

___________________________________ ______________________________________________

Adult Medical History Form Page 2

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