Adult Health History (Page 4 of 9) in pdf

Adult Health History Page 4

N O R T H E R N N E V A D A

HOPES

your partner in health.

Condition

Now

Past

Comments

Gout

Gynecological Conditions (Endometriosis)

Gynecological Conditions (Fibroids)

Gynecological Conditions (Other)

Heart Attack

Hepatitis – Type A

Hepatitis – Type B

Hepatitis – Type C

Hepatitis – Other

High Blood Pressure

High Cholesterol

Hip Fracture

Irritable Bowel Syndrome

Kidney Disease / Failure

Kidney Stones

Liver Disease

Migraine Headaches

Osteoporosis

Pneumonia

Prostate (enlargement)

Prostate (nodules)

Seizure / Epilepsy

Skin Condition (Eczema)

Skin Condition (Psoriasis)

Skin Condition (Abnormal Moles)

Sleep Apnea

Stomach Ulcer

Stroke

Thyroid (Nodule)

Thyroid High (Overactive) /

Hyperthyroidism

Thyroid Low (Underactive) /

Hypothyroidism

Other (list)

SURGICAL HISTORY: Please check off any procedure or surgeries. List any abnormal findings or

complications.

Surgical Procedure

Yes

Year

Comments

Abdominal Surgery

Appendectomy (appendix removal)

Back Surgery (lumbar)

Biopsy (location)

Breast Biopsy

Circle: Right Left Both

Breast Surgery

Circle: Right Left Both

Colonoscopy

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Adult Health History Page 4

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