Adult History Form

Please complete all pages. Your answers on this form will help us understand your medical concerns and conditions better.
If you are uncomfortable with any questions, you do not have to answer it. Best estimates are acceptable.

Please list any prescription and non-prescription medicines, vitamins, home remedies and birth control pills

Medication Dose Times per day

Medication/Foods/Others Reaction or Side Effect

Please indicate whether you have had any of the following medical problems and an approximate date of illnesses or diagnosis

Medical Condition Please Specify Problem & Date of Illness
Congenital Heart Disease
Myocardial Infarction (Heart attack)
Hypertension (High blood pressure)
High Cholesterol
Coagulation (Bleeding/Clotting) Disorder
Cancer (Malignancy)
Depression or Suicide Attempt
Abnormal Pap Smear
Blood Transfusion
Other Problems

Date Surgery Information

For women to answer only

History Details

No. of Pregnancies

No. of Deliveries

No. of Abortions

No. of Miscarriages

1st day of most recent period

Age at 1st period

Frequency of periods

Length of each period (days)

State any concerns you have about your periods

State any concerns you have about menopause

Please indicate if any of your family members have had any of the conditions stated and state your relationship with this member

Medical Condition Relationship
Birth defects
Bleeding problem
Cancer, Breast
Cancer, Colon
Cancer, Melanoma
Cancer, Skin
Cancer, Ovary
Cancer, Prostate
Cancer (Unnoted)