Adult Health History
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9N O R T H E R N N E V A D A
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your partner in health.
Adult Health History
Your answers on this form will help your health care provider get an accurate history of your medical
concerns and conditions. If you are a current patient there is a shorter update form you can use.
Please fill in all five pages. If you cannot remember specific details, please provide your best guess. If
you are uncomfortable with any question, do not answer it. Thank you!
______________________________________________________________________________
PATIENT NAME
TODAY’S DATE
DATE OF BIRTH
Main reason for today’s visit: _____________________________________________________________
Other concerns: _______________________________________________________________________
What are your health goals for the next year? _______________________________________________
Where were you getting your healthcare before? _____________________________________________
In the past two weeks, have you been bothered by:
Little interest or pleasure in doing things?
Yes No
Feeling down, depressed, or hopeless?
Yes No
REVIEW OF SYMPTOMS
Please check and circle any persistent symptoms you have had in the past few months. Read through
every section and check “no problems” if none of the symptoms apply to you. List other concerns above.
GENERAL
Nosebleeds, trouble swallowing
Shortness of breath w/ exertion
Unexplained weight loss / gain
Frequent sore throats, hoarsness
NO problems
Hearing loss / ringing in ears
Unexplained fatigue / weakness
NO problems
Fall asleep when sitting, day
GASTROINTESTINAL
Fever or chills
Heartburn / reflux / indigestion
EYES
NO problems
Blood or change in bowel
Change in vision / eye pain /
movement
redness
SKIN
Constipation
NO problems
New or change in mole
NO problems
Rash / itching
CARDIOVASCULAR
NO problems
Chest pain / discomfort
Palpitations (fast or irregular
BREAST
heartbeat)
Breast lump, pain, nipple
NO problems
discharge
NO problems
GENITOURINARY
RESPIRATORY
Leaking urine
Cough / wheeze
Blood in urine
Loud snoring / altered breath
EARS/NOSE/THROAT
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Parent category: Medical