New Adult Patient Health History

New Adult Patient Health History

Date:*

Date

Name:*

First, Middle and Last Name

Date of Birth:*

Date

Preferred Pharmacy:*

Height:

Weight:

Email:*

example@example.com

Preferred Language:*

Race

Ethnicity

HispanicNon-HispanicOther

Please list family members that are patients or have been seen in our office:

Please answer the following the best you can. Some of these may be difficult to answer and the medical staff will assist you when you are brought to the exam room. Anything left blank will be assumed normal / not present.

What is the reason for today's visit*

Do you have a history of hearing loss or difficulty?

YesNo

Tinnitus (Ringing or buzzing in the ears)

YesNo

Where is the location of the problem?

How often and how long has it occurred?

Is it painful? If so, please explain:

Is it getting worse, improving, or staying the same?

What are some things that make it better or worse?

Other symptoms:

Do you take any blood thinning medications or Aspirin

YesNo

If yes, please list:

List all prescription and nonprescription medicines

Medicine 1

Dose

How Often

Per Day

Medicine 2

Dose

How Often

Per Day

Medicine 3

Dose

How Often

Per Day

Medicine 4

Dose

How Often

Per Day

Medicine 5

Dose

How Often

Per Day

Penicillin Allergy:

YesNo

If Yes, describe reaction:

Environmental Allergies:

YesNo

If Yes, describe:

Other Medication Allergies?

Side Effects / Reaction

Other Medication Allergies?

Side Effects / Reaction

Other Medication Allergies?

Side Effects / Reaction

Other Medication Allergies?

Side Effects / Reaction

Other Medication Allergies?

Side Effects / Reaction

Occupation

WorkingRetiredUnemployedN/A

If working, describe:

Are you under an excessive amount of stress?:

YesNoN/A

Tobacco Use

TobaccoSmokelessOther

Age began

Years Smoked

Average pack per day

Age quit

Alcohol Use

YesNo

If yes: number of drinks per week:

Drug Use:

YesNo

If yes, please describe

1.

2.

3.

4.

	Yes	No	Relationship	Explain
Diabetes
High Blood Pressure
Heart Disease
Cancer
Hearing Loss
Asthma
Stroke
Respiratory Failure
Bleeding Disorders
Anesthetic Complications
Other Inherited Diseases

	Yes	No	Explain
Anesthetic Complications
Eye penetrating injury involving metal
Claustrophobia
Bleeding Problems
Cancer
Skin Changes
Ear, Nose, Throat problems (unrelated to today's visit)
History of Fever, Weight Loss, Chills
Visual Changes
Hearing Problems or Ringing in the Ears
Dizziness / Vertigo
History of Noise Exposure
Are you Pregnant
Cardiovascular Problems (ex: Heart Attack, Chest Pain)
Respiratory Problems (ex: Asthma, Wheezing)
Gastrointestinal Problems (ex: Bloody Stools, Ulcers)
Genitourinary Problems ex: Painful, Bloody Urination)
Musculoskeletal Problems (ex: Arthritis)
Neurological Problems (ex: Stroke, Seizures)
Psychiatric Problems (ex: Depression, Anxiety)
Endocrine Problems (ex: Diabetes, Low Thyroid)
Immune Problems (ex: AIDS, Immune Deficiencies)

Signature*

MEDICATIONS:

ALLERGIES / SENSITIVITIES

SOCIAL HISTORY

PAST SURGICAL / MAJOR ILLNESS HISTORY

FAMILY HISTORY

PATIENT MEDICAL HISTORY