Health History – Primary Care Clinic for Adults

– Step 1 of 9

Preferred Name *

What are we seeing you for? *

What is your Date of Birth? *

Do you have a Latex Allergy? *

Please list all prescriptions, OTC or supplements taken. Please include the dosage and Frequency of use. *

Please list any medication or other allergies and your reaction(s). *

Where else do you go for healthcare?

Will you continue to receive care from that provider?

This question is for continuity and coordination of care only.

Do you need any of the following immunizations (please check all that apply) *

None
Tetanus/Tdap
Hepatitis B
MMR
Pneumococcal
Shingles
Influenza
COVID-19

Gender Identity

What gender was originally listed on your birth certificate? *

Female
Male
Decline to Answer

What are your preferred pronouns? *

Do you think of yourself as: *

Female
Male
Transgender Woman/Trans Woman
Transgender Man/Trans Man
Genderqueer/gender nonconforming-neither exclusively male or female
Decline to Answer

Sexual Orientation-Do you think of yourself as: *

Straight or Heterosexual
Lesbian or Gay
Bisexual
Queer, Pansexual
Questioning or Unsure
Decline to Answer

Social History

Tobacco Use *

When did you quit?

Have you ever used recreational or street drugs? *

Do you feel you have a problem with drugs or alcohol? *

Do you drink alcohol? If so, how many per month? *

Are you concerned about your weight/eating habits? *

How much do you exercise? *

Do you experience any type(s) of abuse in your home? *

Do you wear seatbelts? *

Do you have frequent falls? *

Sexual History

Have you EVER been sexually active? *

How many sexual partners have you had in the past year? *

What gender is/are your sexual partner(s)? *

How do you protect yourself from STI's? *

Have you/your partner had oral/anal sex in the last year? *

Are you currently sexually active? *

How many sexual partners have you had in your lifetime? *

Do you use condoms consistently? *

Do you want to be tested for STI's? *

Contraception

What is your current form of birth control and for how long? *

What (if any) other forms of birth control have you used? What made you change your birth control?

Do you want to change your birth control? *

Do you wish to have children in the future? *

General

My health is generally good. *

Now
In the past
Never

Cancer *

Now
In the past
Never

Sickle Cell Disease *

Now
In the past
Never

Unintentional weight loss or gain of 20lbs or more *

Now
In the past
Never

Type of cancer and when

Skin

Acne *

Now
In the past
Never

Rash, bumps or sores *

Now
In the past
Never

Eyes, Ears, Nose and Throat

EENT

Vision changes *

Now
In the past
Never

Frequent Nosebleeds *

Now
In the past
Never

Hearing problems *

Now
In the past
Never

Eyes-Itching/burning/discharge *

Now
In the past
Never

Nasal Polyps *

Now
In the past
Never

Frequent sore throat *

Now
In the past
Never

ENDOCRINE

Endocrine

Diabetes-Type 1 or 2 *

Now
In the past
Never

Unexplained fever or chills. *

Now
In the past
Never

Hypothyroid *

Now
In the past
Never

Hyperthyroid *

Now
In the past
Never

Hot flashes or Night sweats. *

Now
In the past
Never

NEUROLOGICAL

Neurological

Diagnosed Migraines *

Now
In the past
Never

Seizures (Epilepsy) *

Now
In the past
Never

Persistent Numbness &/or tingling *

Now
In the past
Never

Fainting (Syncope) *

Now
In the past
Never

Severe headaches *

Now
In the past
Never

Stroke (TIA) *

Now
In the past
Never

CARDIOVASCULAR

Cardiovascular

Anemia or Bleeding disorder *

Now
In the past
Never

Heart Murmur *

Now
In the past
Never

Palpitations *

Now
In the past
Never

Heart disease *

Now
In the past
Never

Blood Clots (DVT or PE) *

Now
In the past
Never

High blood pressure (Hypertension) *

Now
In the past
Never

High cholesterol *

Now
In the past
Never

Other

BREASTS

Breasts

Breast surgery *

Now
In the past
Never

Mass or Lump *

Now
In the past
Never

Implants *

Now
In the past
Never

Discharge *

Now
In the past
Never

Tenderness *

Now
In the past
Never

RESPIRATORY

Respiratory

Asthma *

Now
In the past
Never

TB (Tuberculosis) *

Now
In the past
Never

Breathing Problems/Shortness of Breath *

Now
In the past
Never

Chronic Cough *

Now
In the past
Never

GASTROINTESTIONAL

Gastrointestinal

Abdominal Bloating *

Now
In the past
Never

Constipation *

Now
In the past
Never

Heartburn *

Now
In the past
Never

Colitis *

Now
In the past
Never

Gall Bladder Disease *

Now
In the past
Never

Liver Disease or Hepatitis *

Now
In the past
Never

Abdominal Pain *

Now
In the past
Never

Diarrhea *

Now
In the past
Never

IBS (Irritable Bowel Syndrome) *

Now
In the past
Never

Stomach Ulcer *

Now
In the past
Never

Rectal Bleeding *

Now
In the past
Never

Hepatitis Type

MUSCULOSKELETAL

Musculoskeletal

Back Pain *

Now
In the past
Never

Muscle Pain *

Now
In the past
Never

Joint Pain *

Now
In the past
Never

GENITOURINARY (GU)

Genitourinary

Blood in Urine *

Now
In the past
Never

Frequent UTI's *

Now
In the past
Never

Frequent Yeast Infections *

Now
In the past
Never

Kidney Disease or Stones *

Now
In the past
Never

Hernia *

Now
In the past
Never

Frequent Urination *

Now
In the past
Never

Pain or Burning with Urination *

Now
In the past
Never

Genital Rash, Bumps, Sores *

Now
In the past
Never

Pain/Bleeding with Intercourse *

Now
In the past
Never

Urinary Incontinence/Leaking *

Now
In the past
Never

Male GU

GU-Male

Epididymitis or Urethritis

Now
In the past
Never

Unusual Penial Discharge

Now
In the past
Never

Itching or Burning

Now
In the past
Never

Prostate Problems

Now
In the past
Never

Female GU

GU-Female

BV (Bacterial Vaginosis)

Now
In the past
Never

Endometriosis

Now
In the past
Never

PCOS

Now
In the past
Never

Uterine Fibroids

Now
In the past
Never

Abnormal Pap Smear

Now
In the past
Never

Vaginal Itching, Odor, Discharge

Now
In the past
Never

Colposcopy

Now
In the past
Never

Ovarian Cysts

Now
In the past
Never

PID (Pelvic Inflammatory Disease)

Now
In the past
Never

Abn Pap Results

STI's

Chlamydia *

Now
In the past
Never

Gonorrhea *

Now
In the past
Never

HIV *

Now
In the past
Never

Genital Warts or HPV *

Now
In the past
Never

Herpes Simplex (HSV) *

Now
In the past
Never

Syphilis *

Now
In the past
Never

PSYCHOLOGICAL

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ADD/ADHD *

Now
In the past
Never

Depression *

Now
In the past
Never

Mood Swings *

Now
In the past
Never

Anxiety *

Now
In the past
Never

Eating Disorder *

Now
In the past
Never

Under Psychiatric Care *

Now
In the past
Never

MENSTRUAL HISTORY

Please complete this page only if you were born with female reproductive organs.

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What is the first day of your last period?

Was your last period normal?

How old were you when your periods started?

How long do your periods last?

Are your periods:

Have you ever had a pelvic exam?

Do you experience any of the following (check all that apply)?

Severe Cramping before or during your period
Spotting or bleeding between periods
Heavy bleeding

PREGNANCY

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Have you had unprotected sex since your last period?

Do you think you might be pregnant?

Age during first pregnancy?

How many pregnancies?

Any multiple births?

Have you experienced any of the following?

Abortion
Miscarriage
Tubal (ectopic) pregnancy

Are you currently trying to get pregnant?

Have you ever been pregnant?

Age during last pregnancy?

How many live births?

Did you develop diabetes during any pregnancy?

Please let us know which you have had and how many.

Are you currently breastfeeding?

HOSPITAL/SURGICAL HISTORY

Have you had any surgeries? *

Please provide type of surgery/body part and when.

Have you been hospitalized (other than for surgery) or had a major illness?

Please tell us why and when you were hospitalized or what the major illness was.

FAMILY HISTORY

Does any of your family have any of the following? Please specify who.

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Heart Attack or Heart Disease *

No
Unsure
Mother
Father
Sibling

High Cholesterol or Triglycerides *

No
Unsure
Mother
Father
Sibling

Stroke *

No
Unsure
Mother
Father
Sibling

Osteopenia or Osteoporosis *

No
Unsure
Mother
Father
Sibling

Cancer *

No
Unsure
Mother
Father
Sibling

Type of Cancer

Blood Clots (DVT/PE) *

No
Unsure
Mother
Father
Sibling

High Blood Pressure *

No
Unsure
Mother
Father
Sibling

Tay-Sachs or Sickle Cell Anemia *

No
Unsure
Mother
Father
Sibling

Diabetes *

No
Unsure
Mother
Father
Sibling

Tuberculosis *

No
Unsure
Mother
Father
Sibling

Are you adopted? *

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Completed By: *

First

Last

Date Completed:

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