Skip to content
Partner with Mint Health Clinics
Careers
About
Services
Groups
Forms
Contact Us
FAQ
Complete Adult Health History
lpd-admin
2019-02-01T15:28:05-06:00
Health History - Long Form
Step 1 of 6 - Patient Info
0%
Your answers to the following questions will help us to understand your medical history and the concerns you’d like to discuss with your doctor. Please fill out as much of this questionnaire as possible. If you cannot answer some of the questions or feel uncomfortable answering them, leave them blank. Thank you for your help.
Patient Name:
*
Patient Date of Birth:
*
Date Format: MM slash DD slash YYYY
Today's Date:
*
Date Format: MM slash DD slash YYYY
Phone
*
Email
*
What would you like to talk to your doctor about today?
MEDICAL HISTORY
Please list any medication allergies or reactions:
Please check to indicate if you have ever had the following conditions:
Diabetes
High blood pressure
Asthma
Heart attack
Kidney disease
Hepatitis
Thyroid disease
Stroke
Depression
Emphysema
Seizures
Tuberculosis
Coronary Artery Disease
Congestive Heart Failure
Arrythmia
Sexually transmitted disease
Eye problems
Cancer
Other
If checked, Sexually transmitted disease – type:
If checked, Eye problems – type:
If checked, Cancer – type:
Other, please explain:
Please list any surgeries or hospital stays you have had and their approximate date/year:
Type of surgery / reason for hospitalization / location
*
Type of Surgery:
Date:
If you have any other medical problems or serious injuries that are not listed above, please describe them here:
When was your last physical?
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which you are currently taking. Please note the dosage if possible.
Medication Name
Dosage
What pharmacy do you use for prescription medications?
Are you currently receiving care from any other doctors, chiropractors, or other health care professionals? If yes, we would like to know whom so that we can coordinate your care:
Provider’s name
Condition they are treating you for
Please note dates of your most recent immunizations:
Tetanus
Date Format: MM slash DD slash YYYY
Influenza
Date Format: MM slash DD slash YYYY
Pneumonia
Date Format: MM slash DD slash YYYY
Hepatitis B
Date Format: MM slash DD slash YYYY
Other
Date
Date Format: MM slash DD slash YYYY
Other
Date
Date Format: MM slash DD slash YYYY
If you have had any of the following tests done, please note when the tests was done and what the results were, if known:
Cholesterol
Date Format: MM slash DD slash YYYY
Result
Pap smear/pelvic
Date Format: MM slash DD slash YYYY
Result
Mammogram
Date Format: MM slash DD slash YYYY
Result
Blood in stool
Date Format: MM slash DD slash YYYY
Result
HIV
Date Format: MM slash DD slash YYYY
Result
Colonoscopy
Date Format: MM slash DD slash YYYY
Result
Hepatitis C
Date Format: MM slash DD slash YYYY
Result
FAMILY HISTORY
Check any of the diseases that run in your family and please note who had it:
Alcoholism or Drug Use
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Cancer
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Diabetes
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Heart Disease
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
High Blood Pressure
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
High Cholesterol
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Osteoporosis
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Mental Illness
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Stroke
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Thyroid Disease
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Other
None
Mother
Father
Sister
Brother
Grandmother (mother’s side)
Grandfather (mother’s side)
Grandmother (father’s side)
Grandfather (father’s side)
Child
Other
Other (Please explain)
Other Comments:
HEALTH HABITS
Do you smoke or use any tobacco products?
Yes
No
Quit
Number of cigarettes each day?
For how many years?
Other forms of tobacco used?
Do you drink alcohol?
Yes
No
Quit
How much?
How often?
Have you ever felt that you should cut down on your drinking?
Yes
No
Have you regularly used other drugs?
Yes
No
If yes, are you still using them?
Yes
No
PERSONAL HISTORY
Are you currently married or living with a significant other?
Yes
No
Who lives with you at home?
Are you employed?
Yes
No
If yes, what kind of work do you do?
If no, is this by choice?
Yes
No
Disability?
Yes
No
Other Reasons?
Do you exercise more than 2 times per week?
Yes
No
Do you often feel sad or depressed?
Yes
No
Do you feel there is something seriously wrong with your body?
Yes
No
Are you having money problems which limit your access to food, shelter or medical care?
Yes
No
In the last year, have there been any major changes in your life like marriage, divorce, death of a family member or close friend, illness or injury, or change in job situation?
Yes
No
Do you have some form of church or spiritual support?
Yes
No
SEXUAL HISTORY
Are you sexually active?
Yes
No
If yes, with:
Men
Women
Both
Do you feel you are at risk for HIV/AIDS?
Yes
No
Do you have children?
Yes
No
How many children do you have?
Do you use any form of birth control?
Yes
No
If yes, which type / brand?
WOMEN ONLY
Have you ever been pregnant?
Yes
No
How many times?
How many miscarriages?
How many abortions?
How many children do you have living?
Do you have menstrual periods?
Yes
No
If no, at what age did they stop?
If yes, are your periods regular?
OTHER COMMENTS:
Other Comments
Agreement
*
I consent to having Pinnacle Medical Clinic's website store my submitted information so they can respond to my inquiry.
Phone
This field is for validation purposes and should be left unchanged.
This iframe contains the logic required to handle Ajax powered Gravity Forms.
