Health History – A Primary Care Clinic for Adults

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– Step 1 of 8

Name *

Today's date *

Date of Birth *

Current Age *

Reason for today's visit? *

Sexual Orientation *

Straight or Heterosexual
Gay, Lesbian or Homosexual
Bisexual
Other
Choose not to disclose

Current Gender Identity (check all that apply) *

Female
Male
Transfemale
Transmale
Nonbinary
Other
Choose not to disclose

Sex Assigned at Birth *

Female
Male

What reproductive organs were you born with?

What personal pronouns do you prefer? *

She/Her/Hers/Herself
He/Him/His/Himself
They/Them/Theirs/Themself
Other

SOCIAL HISTORY

Do you smoke? *

How many do you smoke a day and for how long?

Do you drink alcohol? *

How often do you drink and how much each time?

Do you use any controlled or illegal substances? *

What kind of substances?

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

Would you like information on where to get help?

Do you exercise? *

How often do you exercise and for how long?

Are you concerned about your weight or eating habits? *

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

Do you wear your seatbelt? *

Do you have frequent falls? *

SEXUAL HISTORY

Have you ever had sexual intercourse? *

Are you currently sexually active? *

Do you use condoms consistently? *

New sexual partner in the last 60 days? *

Anal or oral sex in the past 12 months? *

Do you want to be tested for any S.T.I's? *

Have you been treated for any S.T.I.'s in the last 12 months? *

How do you protect yourself from S.T.I.'s?

Are your sexual partners *

Male
Female
Both

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

How many sexual partners have you had your lifetime? *

PAST MEDICAL HISTORY

GENERAL

My health is generally good *

Currently
In the past
Never

Weight change of 25lbs or more *

Currently
In the past
Never

Fever or Chills *

Currently
In the past
Never

Cancer *

Currently
In the past
Never

Problems Sleeping *

Currently
In the past
Never

Fatigue *

Currently
In the past
Never

SKIN

Rash, Bumps or Sores *

Currently
In the past
Never

Acne *

Currently
In the past
Never

HEAD, EYES, EARS, NOSE AND THROAT

Hair Loss *

Currently
In the past
Never

Eyes: Itching, Burning, Discharge, Dryness *

Currently
In the past
Never

Vision Changes *

Currently
In the past
Never

Ear Pain *

Currently
In the past
Never

Hearing Problems *

Currently
In the past
Never

Frequent Nosebleeds *

Currently
In the past
Never

Nasal Polyps *

Currently
In the past
Never

Sinus Congestion *

Currently
In the past
Never

Sinus Pain/Pressure *

Currently
In the past
Never

Mouth Pain or Dryness *

Currently
In the past
Never

Frequent Sore Throat *

Currently
In the past
Never

Vocal Changes *

Currently
In the past
Never

ENDOCRINE

Diabetes Mellitus (DM) *

Currently
In the past
Never

What Type?

DM Type 1
DM Type 2
DM During pregnancy

Thyroid Disorders *

Currently
In the past
Never

What Type?

Hypothyroid (underactive)
Hyperthyroid (overactive)
Thyroid Cancer

Hot Flashes *

Currently
In the past
Never

Night Sweats *

Currently
In the past
Never

NEUROLOGICAL

Severe Headaches *

Currently
In the past
Never

Migraine Headaches (diagosed) *

Currently
In the past
Never

Fainting (Syncope) *

Currently
In the past
Never

Seizures (Epilepsy) *

Currently
In the past
Never

Persistent Numbness or Tingling *

Currently
In the past
Never

Stroke (CVA) *

Currently
In the past
Never

CARDIOVASCULAR

Heart Murmur *

Currently
In the past
Never

Palpitations *

Currently
In the past
Never

High Blood Pressure *

Currently
In the past
Never

Blood Clots-DVT or PE *

Currently
In the past
Never

High Cholesterol *

Currently
In the past
Never

Anemia or Bleeding Disorder *

Currently
In the past
Never

Other Heart Disease *

Currently
In the past
Never

Chest Pain or Tightness *

Currently
In the past
Never

Edema *

Currently
In the past
Never

RESPIRATORY

Asthma *

Currently
In the past
Never

Chronic Cough *

Currently
In the past
Never

TB (Tuberculosis) *

Currently
In the past
Never

Breathing problems not listed

PSYCHOLOGICAL

Depression *

Currently
In the past
Never

Anxiety *

Currently
In the past
Never

Mood Swings *

Currently
In the past
Never

Eating Disorder *

Currently
In the past
Never

Under Psychiatric Care *

Currently
In the past
Never

ADD or ADHD *

Currently
In the past
Never

GASTROINTESTIONAL

Irritable Bowel Syndrome *

Currently
In the past
Never

Diarrhea – Chronic *

Currently
In the past
Never

Constipation – Chronic *

Currently
In the past
Never

Colitis *

Currently
In the past
Never

Gall Bladder Disease *

Currently
In the past
Never

Stomach Ulcer *

Currently
In the past
Never

Abdominal Pain *

Currently
In the past
Never

Abdominal Bloating *

Currently
In the past
Never

Heartburn *

Currently
In the past
Never

Hemorrhoids *

Currently
In the past
Never

Liver Disease or Hepatitis *

Currently
In the past
Never

What Type?

MUSCULOSKELETAL

Joint Pain *

Currently
In the past
Never

Muscle Pain or Weakness *

Currently
In the past
Never

Back or Neck Pain *

Currently
In the past
Never

Sex Do exercise

BREASTS

Surgery *

Currently
In the past
Never

Discharge *

Currently
In the past
Never

Implants *

Currently
In the past
Never

Mass or Lump *

Currently
In the past
Never

Tenderness *

Currently
In the past
Never

FEMALE GU

Abnormal Pap Smear *

Currently
In the past
Never

Blood in Urine *

Currently
In the past
Never

Frequent UTI's/Bladder Infections *

Currently
In the past
Never

Ovarian Cysts *

Currently
In the past
Never

Genital Rash/Bumps/Sores *

Currently
In the past
Never

Frequent Urination *

Currently
In the past
Never

Frequent Yeast Infections

Currently
In the past
Never

Uterine Fibroids *

Currently
In the past
Never

Kidney Disease or Stones *

Currently
In the past
Never

Pain or Burning with Urination *

Currently
In the past
Never

Pain or Bleeding with Intercourse *

Currently
In the past
Never

Vaginal Itching/Odor/Discharge *

Currently
In the past
Never

Urinary Incontinence *

Currently
In the past
Never

Rectal Bleeding *

Currently
In the past
Never

Colposcopy *

Currently
In the past
Never

Syphilis *

Currently
In the past
Never

Chlamydia *

Currently
In the past
Never

Endometriosis *

Currently
In the past
Never

HPV/Genital Warts *

Currently
In the past
Never

Bacterial Vaginosis (BV) *

Currently
In the past
Never

Genital Herpes *

Currently
In the past
Never

Gonorrhea *

Currently
In the past
Never

Pelvic Inflammatory Disease (PID) *

Currently
In the past
Never

Pain or Burning with Urination *

Currently
In the past
Never

Pain or Bleeding with Intercourse *

Currently
In the past
Never

Hernia *

Currently
In the past
Never

Chlamydia *

Currently
In the past
Never

Urinary Incontinence *

Currently
In the past
Never

HPV/Genital Warts *

Currently
In the past
Never

Epididymitis or Urethritis *

Currently
In the past
Never

Gonorrhea *

Currently
In the past
Never

Rectal Bleeding *

Currently
In the past
Never

Genital Herpes *

Currently
In the past
Never

Itching or Burning *

Currently
In the past
Never

Kidney Disease or Stones *

Currently
In the past
Never

Prostate Problems *

Currently
In the past
Never

Syphilis *

Currently
In the past
Never

Unusual Penial Discharge *

Currently
In the past
Never

CONTRACEPTION

What is your current form of birth control? For how long? Any problems? *

Have you tried other forms of birth control tried? If so, any problems? *

Would you like to change your birth control? *

Do you wish to have children in the future? *

PREGNANCY

Have you ever been pregnant? *

Age at first and last pregnancy?

How many total pregnancies?

How many live births?

Any voluntary terminations? If so, how many?

Any miscarriages? If so, how many?

Any ectopic/tubal pregnancies? If so, how many?

Are you trying to get pregnant? *

Have you had unprotected sex since you last period? *

Are you currently breastfeeding?

Are you concerned that you might be pregnant? *

MENSES

What was the first day of your last period? *

How many days does your period usually last? *

How old where you when your periods started? *

Was your last period normal? *

Do you have a period every month? *

Do you experience severe cramps with your periods? *

Do you have spotting or bleeding between your periods? *

Medication, Allergy and Surgical

Please list all medications & supplements that you take, including the dosage and frequency of use. *

Do you have an allergy to Latex? *

Please list any other allergies (medication or environmental) you have and your reaction. *

Please list any surgeries or hospitalizations, including the year (if known). *

Do you see any other providers? This is used for coordination of care purposes. *

Have you ever had a pelvic exam? *

When was your last pap? *

When was your last mammogram? *

FAMILY HISTORY

Has anyone in your family been diagnosed with any of the following? (Please indicate who)

Are you adopted? *

Breast or Ovarian Cancer

No
Unknown
Mother
Father
Brother
Sister

Diabetes

No
Unknown
Mother
Father
Brother
Sister

High Blood Pressure

No One
Unknown
Mother
Father
Brother
Sister

Tuberculosis

No
Unknown
Mother
Father
Brother
Sister

Osteopenia or Osteoporosis

No One
Unknown
Mother
Father
Brother
Sister

History of Inheritable disease

No One
Unknown
Mother
Father
Brother
Sister

Heart Attack, Stroke or Blood Clots

No One
Unknown
Mother
Father
Brother
Sister

High Cholesterol, Lipids or Triglycerides

No One
Unknown
Mother
Father
Brother
Sister

Tay-Sachs or Sickle Cell Anemia

No One
Unknown
Mother
Father
Brother
Sister

Was your mother given DES to prevent miscarriages during pregnancy?

No
Yes
Unknown