General Medical History Form - Adults Page 2
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2GENERAL MEDICAL HISTORY FORM, ADULTS (Continued)
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Long-Term Illness/Chronic Medical Concerns
Surgery History
Illness
Date of Diagnosis
Surgical Procedure
Date
Date of last mammogram
Date of last flex sigmoidoscopy
Date of last lipid test
Above section entered into Epic by Provider: _________________________________
Are you adopted?
yes
no
No
Maternal
Maternal
Paternal
Paternal
Check family members who
Mother
Father
Sister
Brother
Son
Other
Daughter
Grandmo
Grandfath
Grandmo
Grandfath
History
have the following conditions
Coronary Heart Disease
Congenital Heart Disease
Hyperlipidemia (high cholesterol)
Diabetes Mellitus
Depression
Mental Health Problems
High Blood Pressure
Stroke
Cancer – Breast
Cancer – Colon
Cancer – Prostate
Other Cancers: Type___________
Alcoholism/Drug Abuse
Asthma/Allergies
Migraines
Obesity
Anesthesia Problems
Arthritis
Blood Disease/Anemia
Cystic Fibrosis
Genetic Disorders
Stomach/Intestinal Problems
Genital/Urinary problems
Kidney Disease
Lung Problems
Multiple Sclerosis
Osteoporosis
Thyroid Disorders
Tuberculosis
HIV/AIDS
Seizure Disorder
Other:
Provider OK to enter into Epic: _______________
Entered into Epic by PCS Staff:
_________________
Family
If Deceased:
History
Alive
Age at Death
Cause of Death
Mother
OB/GYN
Father
History
Circle One
Sibling
M
F
please indicate date of
Sibling
M
F
delivery and check
Sibling
M
F
outcome for each
Sibling
M
F
Maternal Grandmother
date
Maternal Grandfather
Pregnancy 1
Paternal Grandmother
date
Pregnancy 2
Paternal Grandfather
date
Pregnancy 3
Circle One
Child
M
F
date
Pregnancy 4
Child
M
F
date
Pregnancy 5
Child
M
F
Family Hx and OB/Gyn Hx Entered into Epic by PCS
Spouse/Other
M
F
Staff:__________________________
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Parent category: Medical