Adult Health History Page 2
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9N O R T H E R N N E V A D A
HOPES
your partner in health.
Nighttime urination or increased
Easy bruising
Hay fever / allergies
frequency
NO problems
Frequent infections
Discharge: penis or vagina
NO problems
NEUROLOGICAL
Concern w/ sexual function
Headache
PSYCHIATRIC
NO problems
Memory loss
Anxiety / stress / irritability
MUSCULOSKELETAL
Fainting
Sleep problems
Neck pain
Dizziness
Lack of concentration
Back pain
Numbing / tingling
NO problems
Muscle / join pain
Unsteady gait
WOMEN ONLY
NO problems
Frequent falls
Premenstrual symptoms
NO problems
(bloating, cramps, irritability)
ENDOCRINE
Problem with menstrual periods
Heat or cold sensitivy
Hot flashes / night sweats
NO problems
NO problems
HEMATOLOGIC/LYMPHATIC
ALLERGIC / IMMUNE
Swollen glands
IMMUNIZATIONS: Check off any vaccinations you have had. Add year, if known.
Check this box if you don’t know the information:
Tetanus (Td) ___________
Tetanus w/ Pertussis (Tdap) __________
Varicella (Chicken Pox) shot or illness___________ Pneumovax___________
Influenza (flu shot) __________
Hepatitis A __________
Hepatitis B __________
MMR __________
Zostavax (shingles) __________
HPV __________
WOMEN’S HEALTH HISTORY
Total number of pregnancies __________
Date of last menstrual period (if still menstruating) ________
Age at beginning of periods __________
Age at end of periods (menopause) _____________
MEDICATIONS
Please list (or show us your own printed record) all prescriptions and non-prescription medications, vitamins,
home remedies, birth control pills, herbs, inhalers, etc.
I take no medications
MEDICATION
DOSE (e.g. mg/pill)
HOW MANY TIMES PER DAY?
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