DAVZ02 Adult Medical History

New / Annual Adult Physical Health History Form

Patient Name*

First NameMiddle NameLast Name

Nickname

Date of Birth*

Date

Age

Past Medical History

Please check the chronic medical problems or serious illnesses and injuries you currently have or have had in the past year.

Immunization / Health Screening History

Last Dose of Tdap

Last Flu Shot

Last COVID Shot

Last Date/Year of Colonoscopy

Last Date/Year of Eye Exam

MaleFemale

YesNo

Last Date/Year of PAP Smear Exam

Date of Last Menstrual Period

Last Date/Year of Mammogram

Date of Menopause

Hospitalizations/Surgeries

Family History

Social History

Who do you live with?

Marital status?

Children? Gender and Ages?

Occupation?

Regularly (Four times a week)OccasionallyNo

What type of exercise?

NoneOccasionalModerateHeavy

How much alcohol per week?

NoneOccasionalModerateHeavy

How much caffeine per week?

NeverCurrentFormer

Current of former tobacco quantity?

YesNo

What type, if yes?

Do you follow any special diet?

Do you believe your nutritional intake is adequate?

Medication History / Allergies

Prescription Medications

Over the Counter Medications

Medication Allergies & Recations

Preferred Pharmacy & Location