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Adult Medical History Form _______________

Please complete All 3 PAGES Name

Your answers on this form will help your clinician understand your medical concerns and conditions better. If you are
uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details.
Thank you!

PRESENT HEALTH CONCERNS: _______________________________________________________________


____________________________________________________________________________________________
____________________________________________________________________________________________
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills,
herbs:
Medication Dose Times Medication Dose Times
per per
day day

ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS:


Medication Reaction or Side Effect

PERSONAL MEDICAL HISTORY:


Please indicate whether you have had any of the following medical problems (with approximate date of illness or
diagnosis):
____Congenital Heart disease: ____Coagulation (bleeding/clotting) Other problems
specify type disorder _________________________
__________________ ____Cancer (Malignancy)
_________________________
____Myocardial Infarction (Heart specify type________________
attack) ____Depression/suicide attempt _________________________
____Hypertension (High blood ____Alcoholism
When was your last Tetanus shot?
pressure) ____If you have ever had a blood
____Diabetes transfusion, please specify date _________________________
____High cholesterol____ _____Abnormal Pap smear
____Stroke ____
____Thyroid problem
specify type__________________

SURGICAL HISTORY (Please list all prior operations and dates):


Operation Date Operation Date

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WOMEN’S GYNECOLOGIC HISTORY:
For Women: # pregnancies:____ # deliveries:____ # abortions: ____ # miscarriages: _____
1st day, most recent period: ______ Age at 1st period:____ Frequency of periods:______ Length of each: _____
Do you have any concerns about your periods? No Yes: __________________________________________
Do you have any concerns about menopause? No Yes: ______________________________________________

FAMILY HISTORY:
Please indicate with a check (√) family members who have had any of the following conditions:

Mom Dad Sist. Bro. Daug. Son Other Mom Dad Sist. Bro. Daug. Son Other
Medical Condition close Medical Condition close
rela- rela-
tives tives
Alcoholism Genetic diseases
Anemia Glaucoma
Anesthesia problem Hay fever (Allergic
Rhinitis)
Arthritis Hearing problems
Asthma Heart Attack (Coronary
Artery Disease)
Birth Defects High Blood Pressure
(Hypertension)
Bleeding problem High cholesterol
(Hyperlipidemia)
Cancer, Breast Kidney diseases
Cancer, Colon Lupus (Systemic Lupus
Erythematosis)
Cancer, Melanoma Mental retardation
Cancer, skin (except Migraine headaches
melanoma)
Cancer, Ovary Mitral Valve
Prolapse
Cancer, Prostate Osteoarthritis
Cancer (not noted) Osteoporosis
Depression Rheumatoid Arthritis
Diabetes, Type 1 Stroke
(childhood onset)
Diabetes, Type 2 (adult Thyroid disorders
onset)
Eczema Tuberculosis
Epilepsy(seizures) Other:

SOCIAL HISTORY Alcohol Use


Do you drink alcohol? No Yes: # drinks/week_____
SUBSTANCES Is alcohol use a concern for you or others? No Yes
Tobacco Use
Drug Use
Cigarettes
Do you use any recreational drugs? No Yes
Quit: Date__________
Have you ever used needles? No Yes
Never
Current: Smoker: packs/day____ # of yrs ________
EXERCISE:
Other Tobacco: Pipe Cigar Snuff Chew
Do you exercise regularly? No Yes
Are you interested in quitting? No Yes

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SOCIOECONOMICS: Are you interested in being screened for sexually transmitted
Occupation: _______________________________ diseases? No Yes

Education completed: Grade school High school Other concerns?_____________________________________


College Graduate school ___________________________________________________
Years of education ____
SAFETY:
Marital status: Single M Sep D W Co-habiting Do use seatbelts consistently? No Yes
Engaged… Other: ______________________ Do you use a bike helmet regularly? NA No Yes
Is violence at home a concern for you? No Yes
Spouse/Partner’s name: __________________________ Do you feel safe in your current relationship? NA No Yes
Number of children: ____________________________ Do you have a gun in your home? No Yes
Who lives at home with you?_______________________
Other concerns?____________________________________
__________________________________________________

SEXUALITY
Sexual Activity EMOTIONS:
Sexually Active: Yes No Not currently 1. In the past year, have you had 2 weeks or more during which
Current sex partner(s) is/are: male female you felt sad, blue or depressed; or when you lost all interest or
Contraception and Protection pleasure in things that you usually cared about or enjoyed?
Birth Control method:____________________ None needed No Yes
If sexually active, do you practice safe sex? NA No Yes 2. Have you had 2 years or more in your life when you felt
Have you ever had any sexually transmitted diseases (STDs)? depressed or sad most days, even if you felt okay
No Yes sometimes? No Yes
If yes, please include: 3. Have you felt depressed or sad much of he time in the past
_______________________date_______ year? No Yes
_______________________date_______

IMMUNIZATIONS:
Please list your most recent immunizations. You do NOT need to include any immunizations given at Harvard
Vanguard Medical Associates. Please include your best estimate of the month and year of each
immunization:
Hepatitis A ____ Measles ____Mumps____Rubella____ Pneumovax (Pneumonia)____
Hepatitis B ____ MMR____
Tetanus (Td) ____ Varicella (chicken pox) shot ____ Other ____

REVIEW OF SYSTEMS: Please check (√) any current problems you have on the list below.
Constitutional Chest (breast) Skin
___Fevers/chills/sweats ___Breast lump/discharge ___ Rash or mole change
___Unexplained weight loss/gain Respiratory Neurological
___Fatigue/weakness ___Cough/wheeze ___Headaches
___Excessive thirst or urination ___Difficulty breathing ___Dizziness/light-headedness
Eyes Gastrointestinal ___Numbness
___Change in vision ___Abdominal pain ___Memory loss
Ears/Nose/Throat/Mouth ___Blood in bowel movement ___Loss of coordination
___Difficult hearing/ringing in ___Nausea/vomiting/diarrhea Psychiatric
ears Genitourinary ___Anxiety/stress
___Problems with teeth/gums ___Nighttime urination ___Problems with sleep
___Hay fever/allergies ___Leaking urine ___Depression
Cardiovascular ___Unusual vaginal bleeding Blood/Lymphatic
___Chest pain/discomfort ___Discharge: penis or vagina ___Unexplained lumps
___Leg pain with exercise ___Sexual function problems ___Easy bruising/bleeding
___Palpitations Musculo-skeletal Other (please specify)_______
AB 11/29/03 ___Muscle/joint pain ________________________

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