Adult Medical History Form

Please complete All 4 PAGES Name

Your answers on this form will help your clinician understand your medical concerns and conditions. If you are uncomfortable with
any question, do not answer it. Best estimates are fine if you cannot remember specific details. Thank you!

PERSONAL INFORMATION:
Preferred name (if different from above):
What language would you prefer to use with us?
Address (if changed since your last visit to our practice, or if you are unsure that we have it):
Street City/town; state; zip code Home
phone: ; work phone ; cell phone
What is the best way for our office to contact you? Please circle one or more of above. If you prefer e-mail, please sign up
for MyHealth, our secure e-mail site, and circle “MyHealth” on this line.
Emergency contact:
Name Relationship home phone work phone cell phone

PRESENT HEALTH CONCERNS:

MY HEALTH CARE GOALS:

MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills,
herbs; please continue additional medications on the other side of this page: I take no regular medications.
Medication Dose Times Medication Dose Times
per per
day day

ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS: I am not allergic to any medications.

Medication Reaction or Side Effect

PERSONAL MEDICAL HISTORY: Acid reflux (heartburn)

Alcoholism / other addiction
Do you have any of the following problems?
Allergies (environmental)
Page 1 of 4
 Anxiety
Asthma
Atrial fibrillation
Cancer (specify type ) Diabetes mellitus
Coagulation (bleeding or clotting) problem Erectile dysfunction
Cholesterol problem Heart disease (specify type )
Chronic low back pain Hypertension (high blood pressure)
Depression Irritable bowel syndrome
Migraines
Osteopenia or Osteoporosis
Prostate problem
Thyroid problem
Other problems (list below):

Have you ever had any of the following problems? If so, please provide approximate year:
Cancer of
Heart attack? Blood transfusion?
please specify
Stroke (CVA) Seizure?

SURGICAL HISTORY (Please list all prior operations and dates):

haveI had no prior surgery.
Operation Date Operation Date

FAMILY HISTORY:
Please indicate with a check () family members who have had any of the following conditions: do not
I know my family history.
Mom Dad Sist. Bro. Daug. Son Other Mom Dad Sist. Bro. Daug Son Other
Medical Condition close Medical Condition . close
rela- rela-
tives tives
Alcoholism Genetic diseases
Anemia Glaucoma
Anesthesia problem Hay fever (Allergies)
Arthritis Hearing problems
Asthma Heart Attack (CAD)
Birth Defects High Blood Pressure
Bleeding problem High cholesterol
Cancer, Breast Kidney diseases
Cancer, Colon Lupus (SLE)
Cancer, Melanoma Mental retardation
Cancer, other skin Migraine headaches
Cancer, Ovary Mitral Valve Prolapse
Cancer, Prostate Osteoarthritis
Cancer (not noted) Osteoporosis
Colon Polyps Rheumatoid Arthritis
Depression Stroke (CVA)
Diabetes, Type 1 (child) Thyroid disorders
Diabetes, Type 2 (adult) Tuberculosis
Eczema Other:
Epilepsy (Seizures)

Page 2 of 4
SOCIAL HISTORY
SUBSTANCES:
Tobacco Use
Alcohol Use
Please check one:
Do you drink alcohol? Never Occasionally Regularly
I have never smoked. Average# drinks/week: 5 oz glasses wine;
I have smoked, but rarely. 12 oz cans beer; 1.5 oz shots hard liquor
When was the last time? Is alcohol use a concern for you or others? No Yes

Drug Use
Other Tobacco:PipeCigarSnuffChew Are you interested in quitting?NoYes Do you use any recreational drugs? No Yes
Have you ever used needles? No Yes

PREFERRED PHARMACY: _
SEXUALITY: Include Address if not HVMA Pharmacy
Sexual Activity SOCIOECONOMICS:
Yes No Not currently Ethnic Background: How would you best describe yourself?
Current sex partner(s) is/are: male female (check only one)
Asian Black, Non-Hispanic Hispanic
Contraception and Protection Native American Native Hawaiian & Other Pacific Islander
Birth Control method: None needed White, Non-Hispanic Other Decline
If sexually active, do you practice safe sex?
Have you ever had any sexually transmitted diseases (STDs)? Marital status: Married Sep Div Widow
N Co- :
If yes, please include: date Spouse/Partner’s name:
Are you interested in being screened for sexually transmitted diseases?

Number of children:
Other concerns? Who lives at home with you?

Occupation:
SAFETY: Education completed: Grade school High school
Do use seatbelts consistently? College Graduate school
Do you use a bike helmet regularly?
Is violence at home a concern for you?
Are you currently in a relationship? No Yes
If yes, do you feel safe in this relationship? No Yes EMOTIONS:
Do you have a gun in your home? Over the past two weeks, how often have you been bothered by any of
Other concerns? the following problems?
Please insert appropriate number for each question, using
EXERCISE: the following scale:
How active are you? 0 = Not at all
I get a cardiovascular work-out 3 or more times/week. I 1= Several days
walk daily but do not work out. 2 = More than half the
I exercise or walk less than 3 times/week. I days 3 = Nearly every day
am not generally active.
[other]  Little interest or pleasure in doing things?
 Feeling down, depressed or hopeless?

Page 3 of 4
IMMUNIZATIONS:
Please list your most recent immunizations. You do NOT need to include any immunizations given at Atrius Health. Please include
your best estimate of the month and year of each immunization:

Hepatitis A Measles Mumps Rubella Pneumovax (Pneumonia)

Hepatitis B
MMR Meningitis Shingles
HPV
Varicella (chicken pox) shot Other
Tetanus (Td)
TdaP

REVIEW OF SYMPTOMS: Please check () any current problems you have on the list below.
Breasts Palpitations Neurological
Breast pain/lump/discharge Gastrointestinal Headaches
Constitutional Abdominal pain Dizziness/light-headedness
Fevers/chills/sweats Heartburn Numbness
Unexplained weight loss/gain? Bloody/black bowel movement Memory loss
Fatigue/weakness Nausea/vomiting/diarrhea Loss of coordination
Eyes Constipation Psychiatric
Change in vision Change in bowel habits Anxiety/stress
E ars/Nose/Throat/Mouth Genitourinary Problems with sleep
Difficult hearing Nighttime urination Depression
Ringing in ears Difficulty starting urination Skin
Problems with teeth/gums Leaking urine Rash or mole change
Hay fever/allergies Painful urination Itching
Respiratory Blood in urine Blood/Lymphatic
Cough/wheeze Discharge from penis Unexplained lumps
Difficulty breathing Sexual function problems Easy bruising/bleeding
Cardiovascular Musculoskeletal Endocrine
Chest pain/discomfort Muscle/joint pain or swelling Excessive thirst or urination
Leg pain with exercise
Other (please specify)

I have none of the above problems.

Revised: June 2011; AB/IM Design