Fillable Printable Adult Health Assessment Form - Pennsylvania

Adult Health Assessment Form - Pennsylvania

Adult Health Assessment Form

We strive t o keep our medical records regarding your health history

accurat e and up to date. To ass ist us in this effort we ask that you print out

and complete the following questionnaire befo re your upcoming vis it. This

is particularly important if you a re new to the practice or returning for an

annual physic al or pre-operat ive evalu ation.

We recognize t hat you may have pre vious ly provided us with s ome of t his

information. We appreciate your cooperatio n in bein g as thorough as

possible so that we may include any details that might have been missed in

prior reviews.

Please bring the completed form wit h you on the day of your appointment

and give it t o t he nurse or medical assist ant who escorts you to the

examinati on roo m.

ADULT HEALTH ASSESSMENT FORM

Patient nam e

Date of Birth

In order to help us deliver quality health care, we would appreciate your responses to the

personal history questions below. You should feel free to discuss any questions you have

concerning these items with your provider.

Do you have any particular health concerns that you w ould like to discuss with your provider?

PROBLEM LIST

Do you have any ongoing medical problems that are under treatment at present?

Examples: High Blood Pressure, Asthma or Diabetes

Condition Date Comments

PAST MEDICAL HISTORY

Have you had any prior medical conditions that have now resolved?

Examples: Pneumonia or Broken Bone

Condition Date Comments

PAST SURG ICAL HISTORY

Procedure Date Comments

Please list all MEDICATIONS that you are currently taking including doses

Don't forget Inhalers, Nasal Sprays, Skin Creams and Over the Counter agents

Medication Strength Dosing

Do you have any ALLERGIES to medications, foods, or other substances?

Agent Reaction Comment Date

Health Maintenance Date Immunizations Date

Colonoscopy Tetanus Vaccine

PSA Influenza Vaccine

Mammography Pneumonia Vaccine

Pap Smear Shingles Vaccine

DEXA Scan Hepatitis B

Lipids (Cholesterol) Hepatitis A

Name

REVIEW OF SYSTEMS

SKIN: RESPIRATORY: MUSCULOSKELETAL:

pigmentation cough fracture

rash persistent cough back pain

scaling persistent sputum arthritis

itching sputum gout

bruising coughing up blood fibromyalgia

lumps or bumps shortness of breath muscular weakness

hair changes wheezing or shortness nocturnal cramping

nail changes of breath with exertion joint pain

psoriasis

CARDIOVASCULAR: NEUROLOGIC:

rosacea palpitations headaches

seborrhea rapid heartbeat migraine headaches

skin malignancy irregular heart beat fainting

recurrent herpes chest pain seizures

EYES: chest pain with exertion paralysis

cataracts shortness of breath at night numbness or tingli ng of hands

visual blurring shortness of breath lying flat numbness or tingli ng of feet

double vision lower extremity edema involuntary movements

glaucoma cyanosis tremor

eye pain calf pain when walking neuropathy

color blindness phlebitis benign positional vertigo

glasses or contacts varicose veins

PSYCHIATRIC:

blind spots

GASTROINTESTINAL: sleep disturbance

dry eye difficulty swallowing anxiety

conjunctivitis dyspepsia difficulty with memory

uveitis vomiting blood nervous breakdown

visual loss abdominal pain depression

blindness excessive gas or bloating sexual difficulties

xanthelasma dark or tarry stools marital problems

EARS/NOSE/THROAT: blood in the stool abusive relationship

deafness constipation excessive alcohol consumption

tinnitus diarrhea illegal drug usage

vertigo jaundice

HEMATOLOGIC/LYMPHATIC/

nose bleeds nausea

IMMUNOLOGIC:

deviated septum vomiting anemia

frequent colds abdominal cramps bleeding disorder

sinus trouble loose or frequent BMs bruising

persistent sore throat

GENITOURINARY: fever

tonsillitis urinating at night night sweats

bleeding gums difficulty with urination chills

dental problem frequency weight loss

sinusitis hesitancy swollen nodes

hoarseness blood in the urine HIV risk factors

incontinence allergies

urgency hay fever

stress incontinence

ENDOCRINE:

urge incontinence goiter

erectile dysfunction thyroid disorder

diabetes

osteoporosis

Name hyperlipidemia

SUBST ANCE & SE XUALI TY

Tobacco Use

I have NEVER smoked

I smoked in the past but I have QUIT

I am exposed to PASSIVE smoke

YES I currently smoke

How much did or do you smoke ? Packs/Day

How long had or have you smoked ? Years

When did you most recently quit ? Date Quit

What kind of tobacco do you use ? Cigarettes

Pipe

Cigar

Snuff

Comment_______________________________________ Chew

Alcohol Use I don't consume alcohol

I consume alcohol on occasion

How many drinks containing 0.5 oz of

alcohol do you consume per week ? Can(s) of beer

Glass(es) of wine

Comment_______________________________________ Shot(s) of liquor

Drug Use

I don't use drugs

I use drugs on occasion

Please indicate your frequency of

use per weeks for each substance:

Cocaine

Marijuana

Comment_______________________________________ Other

Sexual Activity I am not currently sexually active

I have never been sexually active

I am sexually active at present

I partner with Male

Female

I use the Birth control/Protection Condom

Pill

Diaphragm

IUD

Surgical

Spermicide

Implant

Rhythm

Injection

Sponge

Inserts

Comment_______________________________________ Abstinence

Name

Family History Worksheet

Please indicate any MEDICAL HISTORY in your family members

Mo Fa Sis Bro Dau Son MGMo MGFa PGMo PGFa GChild MAunt MUnc PAunt PUnc

Other

Alcohol/Drug

Allergies

Alzheimer's Disease

Anesthesia

Aneurysm

Arthritis

Asthma

Cancer-Other

Breast Cancer

Colon Cancer

Melanoma

Nonmelanoma Skin Cancer

Ovarian Cancer

Prostate Cancer

CAD

Depression

Diabetes

Eczema

Hypertension

Lipids

Migraine Headache

Osteoporosis

Stroke

STATUS Mo Fa Sis Bro Dau Son MGMo MGFa PGMo PGFa GChild MAunt MUnc PAunt PUnc

Please indicate whether your family members are living or deceased. If deceased, please give the age at death and cause if known

Alive

Deceased

age at death

cause of death

Name

Soci oEconomic

Occupation

Employer

Comment

Family

Marital Status

Spouse's Name

Number of Children

Education

Years of Education

ADL & Other Concerns

Military Service

Blood Transfusions

Caffeine Concern

Occupational Exposure

Hobby Hazards

Sleep Concern

Stress Concern

Weight Concern

Special Diet

Back Care

Exercise

Bike Helmet

Seat Belt

Self-Exams

Falls

Name