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.

	Have or have had in past year	Details, if needed
High Blood Pressure
High Cholesterol
Heart Disease
Asthma
Hypothyroidism
Diabetes
Epilepsy
Stroke
Arthritis
Bleeding Disorder
Kidney Disease
Depression
Cancer-what type?
Anxiety
Other

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

Sex

MaleFemale

Are your menses regular?

YesNo

Last Date/Year of PAP Smear Exam

Date of Last Menstrual Period

Last Date/Year of Mammogram

Date of Menopause

Hospitalizations/Surgeries

	Year	Reason	Hospital
1.
2.
3.
4.
5.
6.

Family History

	Age	Illness or cause of death	Age at Death
Father
Mother
Brother
Brother
Sister
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Social History

Who do you live with?

Marital status?

Children? Gender and Ages?

Occupation?

Do you exercise?

Regularly (Four times a week)OccasionallyNo

What type of exercise?

Alcohol Usage

NoneOccasionalModerateHeavy

How much alcohol per week?

Caffeine Usage

NoneOccasionalModerateHeavy

How much caffeine per week?

Tobacco Usage

NeverCurrentFormer

Current of former tobacco quantity?

Do you currently use or have you used illicit drugs?

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