Adult History Questionnaire

Name:

DOB:

Age:

Referring Physician:

Primary Care Physician:

Chief Complaint:

Past Medical History:

Past Surgic History:

Please list allergies of any kind, and include reactions:

Present Medications & Doses:
(Please include all prescription and non-prescription medications.)

Obstetrical History

# of Pregnancies:

# of Children:

Age at first live birth:

Age of menarche:

Age of menopause:

Social History/Habits

Tobacco: YesNo
Type:
Times per day:

Exercise: YesNo
Times per week:
Caffeine:

Alcohol: YesNo
Times per week:

Street Drugs: YesNo

Family History
(Please fill out the fields as they apply and leave blank the ones that do not.)

Father's Age:
Father's Health: GoodFairPoor
Father's Age at Death:
Cause of Death:

Mother's Age:
Mother's Health: GoodFairPoor
Mother's Age at Death:
Cause of Death:

Brother/Sister:
Health: GoodFairPoor
Age at Death:
Cause of Death:

Brother/Sister:
Health: GoodFairPoor
Age at Death:
Cause of Death:

Select if any blood relatives (mother, father, brother, sister, aunt, uncle, grandfather, grandmother) have had any of the following:

Stroke: YesNo
Cancer: YesNo
High Blood Pressure: YesNo
Tuberculosis: YesNo
Diabetes: YesNo
Leukemia: YesNo
Epilepsy: YesNo
Emphysema: YesNo
Bleeding Tendency: YesNo
Heart Attack: YesNo
Kidney Disease: YesNo
Arthritis: YesNo
Colitis: YesNo
Rheumatic Heart: YesNo
Congenital Heart: YesNo
Died Suddenly: YesNo
Heart Failure: YesNo

 
Please leave this field empty.

Please check the appropriate box to indicate if you have or have not had problems with any of the following, and describe in the space provided.

GENERAL HEALTH

Fever: YesNo

Chills: YesNo

Fatigue or Tiredness: YesNo

Cancer: YesNo

Unexplained Weight Loss or Gain: YesNo

EYES

Disease/Injury: YesNo

Blurred Vision: YesNo

Double Vision: YesNo

Glaucoma: YesNo

EARS/NOSE/MOUTH/THROAT

Hearing Loss: YesNo

Ringing in Ears: YesNo

Earaches/Drainage: YesNo

Nosebleeds: YesNo

Chronic Sinus Problems: YesNo

Mouth Sores: YesNo

Sore Throat: YesNo

Voice Changes: YesNo

Swollen Neck Glands: YesNo

CARDIOVASCULAR

Heart Trouble: YesNo

Chest Pain/Angina: YesNo

Rheumatic Fever: YesNo

Irregular or Fast Heartbeat: YesNo

High Blood Pressure: YesNo

Swelling of Feet/Hands: YesNo

RESPIRATORY

Shortness of Breath: YesNo

Coughing: YesNo

Spitting up Blood: YesNo

Asthma/Wheezing: YesNo

GASTROINTESTINAL

Change in Bowel Movements: YesNo

Nausea/Vomiting: YesNo

Frequent Diarrhea: YesNo

Rectal Bleeding/Blood in Stool: YesNo

Abdominal Pain/Heartburn: YesNo

Peptic or Stomach Ulcers: YesNo

Colitis: YesNo

Gallbladder Disease: YesNo

GENITOURINARY

Frequent Urination: YesNo

Burning/Painful Urination: YesNo

Blood in Urine: YesNo

Incontinence or Dribbling: YesNo

Kidney Stones: YesNo

Sexual Difficulty: YesNo

Male -- Testicle Pain: YesNo

Female -- Irregular Periods: YesNo

Female -- Planning Pregnancy: YesNo

Female -- Menopause: YesNo

Sexually Transmitted Disease: YesNo

MUSCULOSKELETAL

Joint Pain: YesNo

Muscle Pain: YesNo

Muscle Weakness: YesNo

Joint Stiffness/Cramping: YesNo

Gout: YesNo

Arthritis: YesNo

SKIN/BREAST

Rash or Itching: YesNo

Change in Skin Color: YesNo

Change in Hair/Nail Color: YesNo

Varicose Veins: YesNo

Breast Pain: YesNo

Female -- Breast Discharge: YesNo

NEUROLOGICAL

Stroke: YesNo

Frequent Headaches: YesNo

Lightheadedness/Dizziness: YesNo

Seizures: YesNo

Numbness/Tingling: YesNo

Tremors: YesNo

Head Injury: YesNo

Blackout/Loss of Consciousness: YesNo

PSYCHIATRIC

Nervousness: YesNo

Depression: YesNo

Insomnia: YesNo

ENDOCRINE

Hormone Problems: YesNo

Thyroid Disease: YesNo

Diabetes: YesNo

Excessive Thirst: YesNo

Excessive Urination: YesNo

Heat/Cold Intolerance: YesNo

Dry Skin: YesNo

HEMATOLOGY/LYMPHATIC

Slow to Heal After Cuts: YesNo

Bleeding/Bruising Tendency: YesNo

Anemia: YesNo

Past Transfusions: YesNo

Enlarged Glands: YesNo

Jaundice: YesNo

Hepatitis: YesNo

ALLERGIC/IMMUNOLOGIC

Food Allergies: YesNo

Environmental Allergies: YesNo

Latex Allergies: YesNo