General Medical History Form - Adults
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1
2General Medical History Form: ADULT
Name:
Date:
GHC-SCW#:
Address:
City:
State:
Zip Code:
Home Phone: (
)
Work Phone: (
)
email:
DOB:
Marital Status:
Divorced
Separated
Married
Sig Other
Single
Widowed
Other
(2)
(3)
Maiden/Other Names:
(1)
Emergency Contact 1:
Relation:
Hm:(
)
Wk:(
)
Emergency Contact 2:
Relation:
Hm:(
)
Wk:(
)
Occupation:
Employer:
Ethnic Group:
African American
American Indian/Eskimo
Asian/Pacific Islander
Caucasian
Hispanic/Latino
Multi-Racial
Language Preference:
Cultural Needs and Preferences:
Allergies (include date noted if known):
Health concerns to be addressed
at appointment:
Medications (include dose if known):
Females: Last menstrual period: ____________ Frequency of menstruation: every _____ days # of days you flow _____
Last Pap: ____________
Normal
Abnormal PMS:
No
Yes
Cramping:
None
Mild
Moderate
Severe
Tobacco Use Status:
Current
Former
Never
Does anyone in the household use tobacco?
Yes
No
Comments: _____________________
Cigarette packs/day:______ #Years:_______ Quit Date:________ Other types:
Pipe
Snuff
Cigar
Chew
Alcohol:
No
Yes
oz/week:
Comment:
Drug Use:
No
Yes
times per week:_____
IV use
Comment:
Sexual Health:
Partners:
Male
Female
Date and Diagnosis of any sexually transmitted disease:
Sexually Active:
Not Currently
Yes
No
______________________________________________
______________________________________________
Contraception Method:
Condom
Injection
Sponge
Symptoms of discharge, itching or lesions: ____________
Pill
Insert
Abstinence
Diaphragm
Surgical
_____________________________________________ _
Spermicide
Implant
Rhythm
IUD
Other:
Activities of Daily Living / Misc:
Check here if there has been no change in this area since you last completed this form
Military Service: ............ No
Yes
Sleep Concern: ............. No
Yes
Exercise regularly: ........
No
Yes
Blood Transfusion: ........ No
Yes
Stress Concern: ............ No
Yes
Wear Bike Helmet: .......
No
Yes
Caffeine Concern: ......... No
Yes
Weight Concern: ........... No
Yes
Wear Seat Belt: ............
No
Yes
Occupational Exposure:
No
Yes
Follow Special Diet:… ... No
Yes
Perform Self Exams: ....
No
Yes
Hobby Hazards: ............ No
Yes
Practices Back Care: .... No
Yes
Other: _________________________
Immunization Dates:
Check here if there has been no change in this area since you last completed this form
Tetanus Booster: ________________________
Hepatitis B: _____________________________
Chicken Pox (or date of illness) ______________
Hepatitis A: _____________________________
Influenza: _______________________________
MMR: _________________________________
Pneumovax: ______________________________
Rubella: titer date: ________ disease date: ______
Other: __________________________________
Other: ___________________________________
Entered into Epic by PCS Staff: _______________________________ Date: ______________
over please
NUR03-002-04(4/08)
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