Health Literacy Universal Precautions Toolkit, 2nd Edition

Adult Initial Health History

[Microsoft Word file Microsoft Word version - 75.5 KB]

Name (First, Middle, Last):

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

Today's Date: ___________________________________

Date of Birth: ___________________________________ 

Address:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Telephone Number (home) (______)___________________________________

                                  (cell) (______)____________________________________

                                  (work) (______)___________________________________

Filling out this form

  • Answering these questions will help your doctor understand your health and how best to treat you.
  • If you need help filling out this form:
    • Bring this form with you to your appointment and a nurse will help you.

      OR

    • Call the clinic at [555-1212 ext. 123] before your appointment and someone can help you over the phone.

Bring to your appointment:

  1. This Initial Health History Form and any other important medical records.
Icon: a pen fills out a form.
  1. Your insurance information.
Icon: a hand holds an insurance card.
  1. All your medicines (prescription, herbal, over-the-counter pills and creams).
Icon: medication bottles, pill-cards, and tubes.

We look forward to working with you!


General Health

1.Why did you make this appointment? (Check all that apply.)

___ regular checkup 

___ first appointment to start care with a new doctor

___ switching doctors (from whom:  __________________________________________________________________________________________________)

___ have a specific health problem (if so, explain  __________________________________________________________________________________________________)

2. In general, what do you consider to be your main health problem(s)? (Check all that apply.)

___ heart problems

___ diabetes

___ stomach problems

___ depression/emotional problems

___ ear, nose, or throat problems

___ joint problems

___ high blood pressure

___ other(s)—please explain:

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________

 

3. How would you describe your health?

___ Excellent      ___ Very Good      ___ Good      ___ Fair      ___ Poor

4. Are you taking any prescription medicines?

___ Yes. Please list your medicines below OR  ___ I brought my pill bottles or a list. 

___ No, I do not take any prescription medicines. (If no, go to question #5.) 

Name of medicine Amount/ size of pill How many pills or doses do you take at
Example:
Furosemide
20 mg  2  morning    2  noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed

(Please use the back of this form if you have more prescription medicines.)

5. What over-the-counter medicines, do you take regularly?

___ Pain reliever (for example: Tylenol, Advil, Motrin, Aleve, aspirin)

___ Vitamins 

___ Antacid (for example: Tums, Prilosec)

___ Herbal medicine (please list) ________________________________________________________________________

___ Other (please list) __________________________________________________________________________________

___ None—I do not take any over-the-counter medicines regularly.

6. Have you ever had any allergic reaction (bad effects) to a medicine or a shot?

___ Yes. (Please write the name of the medicine and the effect you had.) 

___ No, I am not allergic to any medicines.

Medicine I am allergic to What happens when I take that medicine
Example:
Atenolol
I get a rash
   
   
   

7. Do you get an allergic reaction (bad effect) from any of the following? (Check all that apply)

___ latex (rubber gloves)

___ grass or pollen

___ eggs

___ shellfish

___ Other (please describe) _________________________________________________________________________

___ No—I have no allergies that I know of.

8. Have you ever been a patient in a hospital overnight?

___ Yes. (If yes, explain EACH reason and when.)

___ No, I have never been a patient in a hospital. (If no, go to question #9)

I was in the hospital because: When
Example:
Heart attack
6 years ago
   
   
   
   

9. Have you ever had a colonoscopy (a test to look at your insides by sending a camera through your bottom)  ___ Yes    ___ No

When ____________________________________________________________

10. Have you ever received a blood transfusion (when you are given extra blood)? ___ Yes     ___ No

When ____________________________________________________________ 

For Women Only

11. Have you ever been pregnant? ___ Yes     ___ No

How many times?___________________________________________________________________________

How many children have you given birth to?______________________________________________

12. Have you had a PAP smear? ___ Yes     ___ No

Date of last one ___________________________________________________________________________

13. Have you ever had a PAP smear that was not normal? ___ Yes     ___ No

14. Have you had a mammogram (breast x-ray)? ___ Yes     ___ No

Date of last one___________________________________________________________________________

Shots

15. When was your last Tetanus shot? Year_______________     ___ never   ___ don’t know

16. When was your last Pneumonia shot? Year_______________     ___ never   ___ don’t know

17. When was your last Flu shot? Year_______________     ___ never   ___ don’t know

Social History

18. Circle the highest grade you finished in school?

Grade School 1   2   3   4   5   6   7   8 High School  9   10   11   12   GED Vocational School 1   2   3  College 1   2   3   4+

19. What language do you prefer to speak? ___ English   ___ Spanish   ___ Other ____________________________________

20. How well can you read?

___ Very well   ___ Well    ___ Not well    ___ I can not read

21. What do you do during the day?

___ Work full-time

___ Work part-time

___ Attend school

___ Take care of children at home

___ Go out most days (shop, visit, appointments)

___ Stay home most days

___ Other ____________________________________________________________ 

ever smoked cigarettes, cigars, used snuff, or chewed tobacco? 

___ No (if no, go to question #23.)

___ Yes

a. When did you start? ____________________________________________________________ 

b. How much per week? ____________________________________________________________ 

c. Have you quit? ___ No     ___ Yes, when ____________________________________________________________ 

d. Do you want to quit? ___ No     ___ Yes    ___ Already Quit

23. Do you drink alcohol?

___ No (if no, go to question #24.)

___ Yes

a. Have you ever felt you ought to cut down on your drinking? ___ Yes     ___ No

b. Have people ever annoyed you by criticizing your drinking? ___ Yes     ___ No

c. Have you ever felt bad or guilty about your drinking? ___ Yes     ___ No

d. Have you ever had a drink first thing in the morning? .___ Yes     ___ No

24. Are you ___ Single ___ Married ___ Partnered ___ Divorced or Separated ___ Widowed?

25. Who lives in your house?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

26. Do you have sex with ___ men      ___ women  ___ both  ___ neither

27. Do you have any beliefs or practices from your religion, culture, or otherwise that your doctor should know? For example:

___ I do not accept blood/blood products because of personal or religious beliefs.

___ I do not use birth control because of personal or religious beliefs.

___ I fast (go without food) for periods of time for personal or religious reasons.

___ I do not eat meat.

___ I do not eat anything that comes from an animal.

___ Other special diets or eating habits. (Please describe.) ____________________________________________________________ 

___ I use traditional medicines or treatments, such as acupuncture or herbs.

___ Other beliefs ____________________________________________________________ 

___ No, I have no specific beliefs or practices that change the course of my health care.

28. Check any of the following things you use to help you walk.

___ Cane    ___ Walker    ___ Wheelchair 

___ Other ____________________________________________________________ 

___ I do not need any help walking

29. Check any of the following types of help at home you receive (paid help or family and friends).

___ Help with cleaning/laundry.

___ Help with shopping.

___ Help with personal care (bathing, dressing).

___ Help with taking my medicines.

___ I do not use any help at home.

30. In the past year, have you been emotionally or physically abused by your partner or someone important to you? ___ Yes     ___ No

31. In the past year have you been hit, pushed, shoved, kicked or threatened by a partner or someone important to you? ___ Yes    ___ No

Exercise

Describe what kind of exercise you do. (Check all that apply.) How many times per week do you exercise? For how long do you exercise each day?
___ walking
___ biking
___ swimming
___ weight training
___ yoga
___ other_______________
___ I do not exercise
___ once per week
___ twice per week
___ 3 times a week
___ 4 times a week
___ 5 times a week
___ 6 times a week
___ 7 times a week or more
___ less than 15 minutes
___ 15-30 minutes
___ 30 – 45 minutes
___ 45 minutes – 1 hour
___ over 1 hour

Comments:

 

Family History

What medical problems do people in your family have?

Family Member Medical Problems
Mother: ___ Diabetes (sugar)   ___ High blood pressure   ___ Heart problems
___ Cancer   ___ Other: __________________________________________
Father: ___ Diabetes (sugar)   ___ High blood pressure   ___ Heart problems
___ Cancer   ___ Other: __________________________________________
Sisters: ___ Diabetes (sugar)   ___ High blood pressure   ___ Heart problems
___ Cancer   ___ Other: __________________________________________
Brothers: ___ Diabetes (sugar)   ___ High blood pressure   ___ Heart problems
___ Cancer   ___ Other: __________________________________________

History of Medical Conditions

Have you ever had any of the following conditions? (Check all that apply)

___ Anemia (low iron blood)   ___ Asthma (wheezing)   ___ Diabetes (sugar)

___ Heart Trouble   ___ Hemorrhoids (piles)   ___ Cancer

___ Hepatitis (yellow jaundice)   ___ Tuberculosis (TB)   ___ Liver Trouble

___ Pneumonia   ___ Rheumatic fever   ___ Ulcers

___ Stroke   ___ High Blood Pressure

___ Skin problems   ___ Depression (feeling down or blue)

___ Epilepsy (fits, seizures)   ___ Anxiety (nerves, panic attacks)

___ VD, STD (syphilis, gonorrhea, chlamydia, HIV)

___ Other_____________________________________________

Review of Symptoms

    Yes No
Sleeping Do you feel tired a lot? ___ Yes ___ No
Do you have trouble falling or staying asleep? ___ Yes ___ No
Do you have other problems with sleep? ___ Yes ___ No
Eating Have you lost your appetite recently? ___ Yes ___ No
Have you lost weight in the last year without trying? ___ Yes ___ No
Do you eat too much or have you gained weight recently? ___ Yes ___ No
Do you have other problems with eating? ___ Yes ___ No
Throat Do you have sore throats a lot? ___ Yes ___ No
Do you have other problems with your throat? ___ Yes ___ No
Ears Do you have trouble hearing? ___ Yes ___ No
Do you wear a hearing aid? ___ Yes ___ No
Do you have constant ringing or noises in your ears? ___ Yes ___ No
Do you have other problems with your ears? ___ Yes ___ No
Back Do you have back pain? ___ Yes ___ No
Do you have any other problems with your back? ___ Yes ___ No
Eyes Do you have trouble with your vision or seeing? ___ Yes ___ No
Do you wear glasses or contacts? ___ Yes ___ No
Do you have other problems with your eyes? ___ Yes ___ No
Nose and Sinuses Do you have a runny or stopped up nose a lot? ___ Yes ___ No
Do you have other problems with your nose or sinuses? ___ Yes ___ No
Teeth and Mouth Do you have sore or bleeding gums? ___ Yes ___ No
Do you wear plates or false teeth? ___ Yes ___ No
Do you have other problems with your teeth and mouth? ___ Yes ___ No
Heart or Breathing Do you ever have pain/tightness in your chest when working or exercising? ___ Yes ___ No
Do you wake up at night with trouble breathing? ___ Yes ___ No
Do you have a racing or skipping heartbeat at times? ___ Yes ___ No
Do you have other heart or breathing problems? ___ Yes ___ No
Bowel Movements Do you have bowel movements (poop) that are black, like tar, or bloody? ___ Yes ___ No
Do you have any other problems with your bowel movements (poop)? ___ Yes ___ No
Peeing and Kidney Stones Do you have trouble passing your urine (peeing)? ___ Yes ___ No
Does it burn when you pass urine (pee)? ___ Yes ___ No
Do you have to pee more than 2 times a night? ___ Yes ___ No
Do you leak urine (pee)? ___ Yes ___ No
Have you ever passed kidney stones? ___ Yes ___ No
Do you have any other problems with your peeing? ___ Yes ___ No
Joints Do you have swollen or painful joints? ___ Yes ___ No
Do you have any other problems with your joints? ___ Yes ___ No
Head, Balance, Fever and Weakness Do you have frequent or severe headaches? ___ Yes ___ No
Have you ever fainted (passed out)? ___ Yes ___ No
Have you lost your balance and fallen recently? ___ Yes ___ No
Do you have weakness in any part of your body? ___ Yes ___ No
Have you had a fever within the past month? ___ Yes ___ No
Do you have any other problems with your head or balance? ___ Yes ___ No
Emotional Health Do you get upset easily? ___ Yes ___ No
Do frightening thoughts keep coming into your mind? ___ Yes ___ No
Have you ever been hospitalized for nerves, thoughts or moods? ___ Yes ___ No
During the past 2 weeks, have you often been bothered by having little interest or pleasure in doing things? ___ Yes ___ No
During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless? ___ Yes ___ No
Do you have any other problems with your emotional health? ___ Yes ___ No
Men Only Have you ever had prostate trouble? ___ Yes ___ No
Do you have any other male problems? ___ Yes ___ No
Women Only Do you have pain or lumps in your breast? ___ Yes ___ No
Do you have unusual vaginal discharge or itching? ___ Yes ___ No
Do you or have you taken hormones (such as birth control pills)? ___ Yes ___ No
Do you have any other female problems? ___ Yes ___ No

Return to Contents

Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Adult Initial Health History. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool11a.html