Health History – A Primary Care Clinic for Adults

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– Step 1 of 9

Name *

Today's date *

Date of Birth *

Current Age *

Reason for today's visit? *

Sex Assigned at Birth *

Female
Male

Current Gender Identity *

Female
Male
Transfemale
Transmale
Nonbinary
Other
Choose not to disclose

Sexual Orientation *

Straight/Heterosexual
Gay/Lesbian/Homosexual
Bisexual
Other
Choose not to disclose

What personal pronouns do you prefer? *

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

SOCIAL HISTORY

Are you a current or former smoker? *

Current
Former
Never Smoked

How many per day and for how long?

Do you drink alcohol? *

How many drinks per day and how often?

Do you use any controlled or illegal substances? *

What substance(s)?

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 and for how long?

Are you concerned about your weight or eating habits? *

Do you wear your seatbelt? *

Do you experience any type of abuse? *

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?

My sexual partners are *

Male
Female
Both
Other

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

How many sexual partners have you had your lifetime? *

MEDICAL HISTORY

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, 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?

MUSCLOSKELETAL

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

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 GENITOURINARY

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

MALE GENITOURINARY

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? *

Syndrome wear or

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? *

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? *

MEDICATIONS, ALLERGIES, HOSPITALIZATIONS/SURGERIES

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? *

Are you adopted? *

FAMILY HISTORY

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

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