Sheryll Chua

Doctor’s Name: _________________________________________________ Clinic Address: __________________________________________________ Clinic Phone: ___________________________________________________ ADULT HEALTH HISTORY Patient’s Name: _________________________________________________________________ Date: ________________________ Address: _______________________________________________________________________ Phone: ______________________ Date of Birth: _________________________________ How would you rate you general health:  Excellent Age: ___________  Good  Fair Gender:  Male  Female  Poor Main reason for today’s visit: ____________________________________________________________________________________ Other concerns: ______________________________________________________________________________________________ MEDICAL HISTORY Check all conditions that you are currently being treated for or have been treated for in the past. YES NO CONDITION Cancer Breast Lung Uterus Colon Bladder Prostate Cervix Other: _____________________________ Circulatory Problems Stroke Blood Clots Leukemia TIA (mini stroke) Hardening of the Arteries Lymphoma High Cholesterol Migraine Other: _____________________________ YES NO CONDITION Heart Problems Chest Pain or Angina Heart Attack Murmur Irregular Heart Beat Congestive Heart Failure High Blood Pressure Heart Valve Disease Other: ______________________________ Skin Problems Psoriasis Acne Other: ______________________________ Ears and Eyes Problems Cataracts Glaucoma Vision Loss Hearing Loss Other: ______________________________ YES NO CONDITION Lung Problems Asthma Fluid in the Lungs COPD or Emphysema Sleep Apnea Pneumonia Other: _____________________________ YES NO CONDITION Stomach Problems Ulcer Liver Disease Heartburn or GERD Diverticulitis Hepatitis Other: ______________________________ Psychological Problems Depression Suicide Attempts Anxiety Hallucinations Bipolar Disorder Obsessive Compulsive Disorder Other: _____________________________ Bone and Joint Problems Lupus Broken Bones Rheumatoid Arthritis Fibromyalgia Osteoarthritis Rheumatic Fever Other: ______________________________ Endocrine Problems Diabetes Thyroid Osteoporosis Other: _____________________________ Infection Tuberculosis HIV Hepatitis Other: ______________________________ Urinary Problems Kidney Failure Loss of Control Kidney Stones Blood in Urine Frequent Bladder Infection Other: _____________________________ For Women Only Pre-menstrual symptoms (bloating cramps, irritability) Problem with menstrual periods Hot flashes / night sweats Unusual vaginal bleeding Cysts/Fibroid Tumors Other: ______________________________ Surgery: List all surgical procedures you’ve had. Type of Surgey Date Medications: List all medications you are currently taking, including prescriptions, non-prescriptions, vitamins and herbal supplements. Medications Dosage Reason Allergies: List all foods and medicines that you have reactions to. Food Reaction Medicine Reaction SOCIAL HISTORY Tobacco Use:  Yes  No  Stopped Alcohol Use:  Yes  No  Stopped If yes, how often: __________________________________ If yes, how often: _________________________________ If stopped, when: __________________________________ If stopped, when : ________________________________ How long did you take it: ____________________________ How long did you take it: __________________________ Drug Use:  Yes Sexually active:  No  Yes Drug/s Used: __________________________________ Did you use IV/needles?  No  No Birth Control Method: _________________________________________ Have you ever had any sexually transmitted diseases (STDs)?  Yes Are you interested in being screened for sexually transmitted diseases? Do you exercise regularly?  Yes  Yes  No  No  Yes  No Do you drink caffeine:  Yes  No No. of cups/day: ___________ Is there anything else you want your doctor to know? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________ Patient’s Signature