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- Adult Hlth Hist2015

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 StephenL.Aronoff,M.D.,F.A.C.E.
DiplomateoftheAmericanBoardofInternalMedicineandtheSubspecialtyBoardofEndocrinologyandMetabolism
2400LakesideBlvd.,Suite130,Richardson,TX75082
Phone:214‐774‐4475Fax:214‐432‐5392

 ADULTPATIENTHEALTHHISTORY
I.GeneralInformation:
Name:_____________________________________________DateofBirth:_________________________
StreetAddress:____________________________________________________Apt.#__________________
City:_____________________________________State:__________________ZIPCODE:_______________
HomePhone:___________________WorkPhone:___________________CellPhone:__________________
Pharmacyname&address:__________________________________________Phone#:________________
Emergencycontactperson:_____________________________________Relationship:_________________
Address(ifdifferentfrompatient):______________________________________________________________
City:_____________________________________State:__________________ZIPCODE:________________
Phone#:____________________________AlternatePhone#:_____________________________________
Patient’sReasonforOfficeVisit:____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
II.Medications:
Pleaselistanyknowndrugallergiesorothernegativereactionstomedications:_____________________
_______________________________________________________________________________________
_______________________________________________________________________________________
PleaselistalldiabetesmedicationsseparatelyonPage5,PartVI“forpatientswithdiabetes.”
Belowpleaselistall
othercurrentlyusedmedicationsincludinginhalers,vitaminsandsupplements.
_______________________________________________________________________________________
Medication Dose Frequency AgeStarted
Name
(mg,ml,sprays,etc.)(perday,perweek,etc.)(orgivedate)
1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________
5.______________________________________________________________________________________
6.______________________________________________________________________________________
7.______________________________________________________________________________________
8.______________________________________________________________________________________
9.______________________________________________________________________________________
10._____________________________________________________________________________________
[AdultHlthHist.‐Page1]


III.GeneralHistory:
MaritalStatus(checkone):___Single___Married___Divorced___Separated___Widowed
Occupation:____________________________________________________________________________
NumberofChildren:_______YearofBirthforeach_____________________________________________
SmokingHistory(checkoneandfillintheblanksifindicated):
____Neversmoked.
 ____Currentlysmoking.Agestarted:____Howmanycigarettesperday?_________________
____Quitsmoking:Agestarted:__________Agestopped:____________
AlcoholIntake(pleasecheckone):____No____Yes____Occasionally
Numberofdrinksperday:____ORNumberofdrinksperweek:____
Exercise:Type:____________________________________Timesperweek:_______________________
DietaryRoutine(checkone):____Balanced(allnutritiongroups)____Diabetic____Vegetarian
____GlutenFree____LowFat____LowSodium
____LactoseIntolerant ____Vegan
____Other:Pleaseexplain_______________________________________
IV.FamilyHistory:____Checkifadoptedornofamilyhistoryisknownandproceedtonextpage.

Pleasecheck
allthatapply
Father Mother Grandfather
MaternalPaternal
Grandmother
MaternalPaternal
Brother Sister
Diabetes 
HeartDisease 
HeartAttack 
Congestive
HeartFailure


HighBloodPressure
 

ThyroidProblems 
Osteoporosis
KidneyDisease
Cancer
Ifyes,typeofCancer:

[AdultHlthHist.‐Page2]
V.PatientDiseaseHistory:
Pleaselistanyseriousorchronicillnesses.____Checkifnohistoryofsuchconditions.
1.___________________________________________________________Dateorage:_________________
2.___________________________________________________________Dateorage:_________________
3.___________________________________________________________Dateorage:_________________
4.___________________________________________________________Dateorage:_________________
5.___________________________________________________________Dateorage:_________________
6.___________________________________________________________Dateorage:_________________
Usethisareaifadditionalspaceisneeded:
VI.MajorSurgeries:Pleaselistbelow.____Checkifnohistoryofmajorsurgery.
1.__________________________________________________________Dateorage:_________________
2.__________________________________________________________Dateorage:_________________
3.__________________________________________________________Dateorage:_________________
4.__________________________________________________________Dateorage:_________________
5.__________________________________________________________Dateorage:_________________
6.__________________________________________________________Dateorage:_________________
Usethisareaifadditionalspaceisneeded:
VII.OverallHealthReview:
Pleasecheckallconditionsthatapply.
GENERALEARS/NOSE/THROATEYES
Fever ___ Hearingimpairment ___ Visionchanges ___
Chills___ Hearingaiduse ___ Visionloss ___
Fatigue ___ Ringinginears ___ Glaucoma ___
Weakness ___ Neckpain ___ Cataracts ___
Dizziness ___ Difficultyswallowing ___ Eyeinjuries ___
Fainting ___ Hoarseness ___
Headaches ___ Voicechanges ___
Stroke ___ Nosebleeds ___
Pain ___
SleepProblems___ (continuedonnextpage…)


[AdultHlthHist.‐Page3]
OverallHealthReview,continuedfrompage3–
SKINPSYCHIATRICSYMPTOMS
 Easybruising  ___ Depression ___
 Dryskin  ___ Anxiety ___
 Rash  ___ MemoryLoss ___ 

URINARYSYSTEM CARDIOVASCULARSYSTEM
 Frequenturination ___ Heartpalpitations
 Difficultyurinating ___ (“pounding”) ___
 Painwhenvoiding ___ Chestpains ___
 Bloodinurine ___ Hypertension ___
 Kidneystones ___
ENDOCRINEandMETABOLICSYSTEMSREVIEW
I.Generalreview‐‐Pleasecheckallconditionsthatapply:
ForMenandWomen:ForWomenOnly:
Rapidweightchange ___ Irregularmenstrualperiods ___
Heatintolerance ___ Excessivefacialorbodyhair ___
Coldintolerance___

II.Womenwithexcessivefacialorbodyhair‐‐pleaseprovidethefollowinginformation:
Whereisthehairlocated?___________________________________________________________
Whendiditappear?________________________________________________________________
Aremenstrualperiodsregular?_______________________________________________________
Hastherebeenrapidweightchange?__________________________________________________
III.Patientswithkidneystones‐‐pleaseprovidethefollowinginformation:
Howmanytimeshaveyouhadkidneystones:_______Atwhatage(s)?________________________
Werestonespassedwithouthospitalization?(checkone)Yes___No___Ifno,whatprocedure
wasusedtoremovestones?_________________________________________________________
Doyounowhavekidneystones?(checkone)Yes___ No___
Havepreviousstonesbeenanalyzed?(checkone)Yes___No___Ifyes,whatweretheresultsof
analysis?__________________________________________________________________________
Haveyoubeenevaluatedforcauseofstoneformation?(checkone)Yes___No___Ifyes,what
weretheresultsofevaluation?________________________________________________________
[AdultHlthHist.‐Page4]
IV.Patientswiththyroidproblems‐‐pleaseindicate(check)ifyouhavethefollowing:
Enlargedthyroid Yes___ No___
Thyroidnodule(s) Yes___ No___
Underactivethyroid Yes___ No___
Overactivethyroid Yes___ No___
Thyroidcancer Yes___ No___
V.Patientswithboneloss(osteoporosisorosteopenia)–pleaseprovidethefollowinginformation:
Dateoflastbonedensityexam:_______________________________________________________
Haveyouhadbonefractures?(checkone)Yes___No___Ifyes,indicatewhichbonesanddateof
fractureforeach___________________________________________________________________
_________________________________________________________________________________
Haveyouhadanylossofheight?(checkone)Yes___No___Ifyes,howmanyinches?_________
Whathasbeenyourtallestheightmeasurement?_______feet_______inches
VI.Patientswithdiabetes‐‐pleasecompletethefollowingsection:
1.Generalinformation:
 AgeofDiagnosis______________ Dateoflasteyeexam:___________________
Dateoflastmicroalbumin______________Results(checkone):Normal_____Abnormal_____
DateoflastHgbA1C ______________ Value:_________________%
Doyouuseaglucosemeter?(checkone)Yes____Brandname:____________________No____
Frequencyofbloodsugartesting____________________timesperday.
Bloodsugarrange_________________________________________________________________
DoyouuseaCONTINUOUSGLUCOSEMONITOR(CGM)?Yes____No____

2.PatientsusingoralmedicationonlyORusingoralmedicationplusinsulin:
Listoralmedications:1.____________________________Dose___________________________
2.____________________________Dose___________________________
3.____________________________Dose___________________________
4.____________________________Dose___________________________
Doyouuseoralmedicationplusinsulin?Yes____No____
Ifyes,pleaseprovidethefollowinginformation:
Longactinginsulin‐‐Brand:_______________________
Timeofdayandamountforeach:_______________________________________________
ShortactingInsulin‐‐Brand:_______________________
Timeofdayandamountforeach:_______________________________________________
Pre‐mixedInsulin‐‐Brand:_______________________
Timeofdayandamountforeach:_______________________________________________
(SECTION2CONTINUEDONNEXTPAGE)
[AdultHlthHist.‐Page5]
ENDOCRINEandMETABOLICSYSTEMSREVIEW,partVI,forpatientswithdiabetes,section2,
Continuedfrompage5–
Forpatientsusingoralmedicationplusinsulin:
Doyouadjustyourinsulin?______________Ifso,bywhatmethod?________________________
_______________________________________________________________________________


3.Patientsinjectinginsulinonly‐‐pleaseprovidethefollowinginformation:

Longactinginsulin‐‐Brand:_______________________
Timeofdayandamountforeach:________________________________________________
ShortactingInsulin‐‐Brand:_______________________
Timeofdayandamountforeach:________________________________________________
Pre‐mixedInsulin‐‐Brand:_______________________
Timeofdayandamountforeach:_______________________________________________
Doyouadjustyourinsulin?______________Ifso,bywhatmethod?________________________
_______________________________________________________________________________
4.Patientsusinganinsulinpump‐‐pleaseprovidethefollowinginformation:
Brandofpump:____________________________________Datestarted:____________________
BasalInsulinRates:_________________________________
Insulin/CarbRatio:_________________________________
InsulinCorrectionFactor:____________________________
IAFFIRMTHATTHEINFORMATIONREGARDINGMYHEALTHPROVIDEDONTHISFORMISCORRECTTO
THEBESTOFMYKNOWLEDGE.
SignatureofPatient:_________________________________________________Date:________________
OR:
SignatureofAuthorizedRepresentative____________________________________Date:_____________
Pleaseprintrepresentative’sname:_________________________________________________________
Relationshiptopatient:___________________________________________________________________
Thank you for completing this health history form. This important information
will help us to better serve your health care needs.
[AdultHlthHist.‐Page6]
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- Adult Hlth Hist2015

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Completed 30 September 2021

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