Name Date
Comprehensive Adult New Patient Health History Questionnaire
Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are
a current patient there is a shorter update form you can use. Please fill in all six pages. It is long because it is comprehensive. We
really want to know you well so we can properly care for you. If you cannot remember specific details, please provide your best guess. If
you are uncomfortable with any question, do not answer it. Thank-you!
Who referred you to my practice?
Circle one: patient, family member, physician, assigned. Name?______________________
Main reason for today’s visit: _______________________________________________________________________________
Other concerns: __________________________________________________________________________________________
What are your health goals for the next year? _________________________________________________________________
How would you rate your health? (circle one): Excellent / Good / Fair / Poor
Please list healthcare providers & their specialty you see regularly: _____________________________________________
List any medical suppliers you use (e.g. respiratory supplies, etc): ________________________________________________
MEDICATIONS: Please list (or show us your own printed record) all prescriptions and non-prescription medications. This includes
vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc).
box if you do not take any prescription or over the counter medications.
Check box if you brought a list of your medications (give it to my assistant and don’t write in medications below).
Medication Dose (e.g. mg/pill) How many times per day?
ALLERGIES or intolerance to medications? NONE
(If yes, to what & what reaction?) _________________________________________________________________________
IMMUNIZATIONS: Enter year (if known) of any vaccinations you have had.
Tetanus (Td) ______ With Pertussis (Tdap) _______ Varicella (Chicken Pox) shot or illness ______ Pneumovax (pneumonia) _____
Influenza (flu shot) _____ Hepatitis A _____ Hepatitis B _____ MMR _____ Meningitis _____ Zostavax (shingles) _____ HPV _____
Lipid (cholesterol) Date ____________________ Result, if known __________________________
Sigmoidoscopy or Colonoscopy (circle one) Date (year)_______________ Abnormal? No Yes
Women only:
No Yes
gram Most recent date/where _____________________ Abnormal? No Yes
Pap Smear Most recent date/where _____________________ Abnor
mal? No Yes
Bone Density Test Most recent date/where _____________________ Abnormal? No
Revised 7/10/2015 please go to next page Page 1 of 6
PERSONAL MEDICAL HISTORY: Do you have now or have you had (past) any of the following conditions?
Condition Now Past Comments
Alcohol / Drug abuse
Allergy (Hay Fever)
Arthritis (Rheumatoid)
Arthritis (Osteoarthritis)
Bladder / Kidney Problems
Blood Clot (leg)
Blood Clot (lung)
Blood Transfusion
Breast Lump (benign)
Cancer Breast
Cancer Colon
Cancer Other Type
Cancer Ovarian
Cancer Prostate
Chicken Pox
Colon Polyp
Coronary Artery Disease
Diabetes (adult onset)
Diabetes (childhood onset)
Emphysema (COPD)
Fractures (broken bones) Where?
Gallbladder Disease
Gastroesophageal Reflux (Heartburn/GERD)
Gynecological Conditions (Endometriosis)
Gynecological Conditions (Fibroids)
Gynecological Conditions (Other)
Heart Attack
Hepatitis Type A
Hepatitis Type B
Hepatitis Type C
Hepatitis Other
High Blood Pressure
High Cholesterol
Hip Fracture
Irritable Bowel Syndrome
Kidney Disease / Failure
Kidney Stones
Liver Disease
Migraine Headaches
Prostate (enlargement)
Prostate (nodules)
Seizure / Epilepsy
Skin Condition (Eczema)
Revised 7/10/2015 please go to next page Page 2 of 6
Personal History continued
Condition Now Past Comments
Skin Condition (Psoriasis)
Skin Condition (Abnormal Moles)
Sleep Apnea
Stomach Ulcer
Thyroid (Nodule)
Thyroid High (Overactive) / Hyperthyroidism
Thyroid Low (Underactive) / Hypothyroidism
Other (list)
Other (list)
Check box if you have no history of significant medical illnesses.
SURGICAL & PROCEDURE HISTORYPlease check off any procedure or surgeries. List any abnormal finding, details or
complications under comments.
Surgical Procedure Code Yes Year Comments
Abdominal surgery HX0004
Angiogram (heart) HX0541
Angiogram (vascular) HX0503
Appendectomy (appendix removal) HX0023
Back surgery (lumbar) HX0032
Biopsy (location in comments) HX0524
Breast Biopsy HX0043 Circle: Right Left Both
Breast surgery HX0056 Circle: Right Left Both
Cataract surgery HX0196
Colonoscopy HX0095
Coronary Bypass HX0526
Coronary Stent HX0243
Echocardiogram (heart)
EGD (Stomach Endoscopy) HX0491
Gallbladder Removal HX0349 Circle: Laparoscopic (HX0271)
Heart Surgery
(other than coronary bypass checked above)
Hip Surgery HX0224 Circle: Right Left Both
Hysterectomy (partial, ovaries left) Circle: Laparoscopic Vaginal Abdominal
Hysterectomy (total, including ovaries) HX0600 Circle: Laparoscopic Vaginal Abdominal
Knee Surgery HX0261 Circle: Right Left Both
LEEP (Cervix surgery) HX0105
Neck (Spine) surgery HX0554
Ovary Removal HX0355 Circle: Right Left Both
Pulmonary Function Test INT0015
Sigmoidoscopy HX0426
Sinus Surgery HX0427
Stress Test (stress echo) HX0433
Stress Test (thallium/perfusion) HX0294
Stress Test (treadmill) HX0191
Tonsillectomy HX00535
Tubal ligation HX00536
Vasectomy HX0356
Other (list)
Check box if you have never had any medical procedures or surgeries.
Revised 7/10/2015 please go to next page Page 3 of 6
Adopted? □ No □ Yes. If adopted and you do not know your family history skip the Family History section and continue to
Health Issues on the next page.
Indicate which relative has had the following diseases (parents, brothers & sisters are the most important). Write in number of siblings in
appropriate boxes.* If some siblings are alive and some are deceased use the space to the right to explain further.
* Sister(s)
* Brother(s)
Mom’s Mom
Mom’s Dad
Dad’s Mom
Dad’s Dad
Age currently or at death
Diseases & Conditions
Mom’s Mom
Mom’s Dad
Dad’s Mom
Dad’s Dad
Other blood
relatives (list
relationship to
List age(s) at diagnosis
if known and if this was the
cause of death
No significant history known
Hypertension high blood pressure
Hyperlipidemia high cholesterol
Heart Attack, Angina
(Coronary Artery Disease)
Diabetes Type II (adult onset)
Cancer, Breast
Cancer, Colon
Cancer, Prostate
Alcoholism / Drug abuse
Autoimmune Disease
Bleeding or Clotting Disorder
Cancer, Lung
Cancer, Ovarian
Cancer, Other type
Colon Polyp
Diabetes Type I (childhood onset)
Emphysema (COPD)
Genetic Disorder (explain)
Heart Disease (CHF)
Heart Disease (Other)
Hepatitis B or C
Hip Fracture
Hypothyroidism / Thyroid Disease
Kidney Disease
Kidney Stones
Macular Degeneration
Sudden Cardiac Death
Other (list)
Other (list)
Revised 7/10/2015 please go to next page Page 4 of 6
cco Use:
Smoke or smoked cigarettes/ pipe/ cigars (circle)?
Never Yes
Exposure to second hand smoke? No Yes
(If never used any tobacco can skip to Alcohol Use section below)
Current smoker: Packs/day: _________ # of years: _________
Former smoker: Quit date: __________
Approximately how many packs/day did you smoke? _______
How many years did you smoke? ________
Other tobacco? (circle) Snuff or Chew
Quit date ________ Currently use? Yes
Are you ready to quit? No Yes
Alcohol Use:
Do you drink alcohol? No Yes
# of drinks/week: ___________ Beer Wine Liquor
How many times in a year have you had >3 drinks (for women)
>4 drinks (for men) in a day? ___________
Drug Use:
Have you ever used recreational drugs? No Yes
If yes, which ones? __________________________________
Quit which ones? All _______________________________
Any used currently? _________________________________
Sexual Activity:
Are you sexually involved: Not currently Never Yes
Sexual partner(s) is/are/have been/may be in future:
male female
Birth control method or STD prevention (check all that apply):
None needed □ Condom □ Pill □ IUD □ Patch □ Ring
Diaphragm Vasectomy Tubal ligation
Other method
Other (ADL):
Military Service? No Yes
lood Transfusion?
Exposure to toxic chemicals at work?
Exposure to toxic chemicals doing hobbies?
o you follow a special diet?
vegetarian, vegan, gluten free, other
Exercise: Do you exercise regularly?
If yes, what kind of exercise?
No Yes
No Yes
No Yes
No Yes
Yes No
How long (minutes)? _____________ How often? ______________
Do you use a helmet for recreational activities?
(e.g. bike, skateboard, ski) Not applicable Yes No
Do you use seatbelts consistently? Yes No
In the past 2 weeks: Have you been feeling down, depressed or
hopeless? No
Do you have little interest or pleasure in doing things?No
ease continue to next column on right
oes your home have a working
smoke detector?
Do you have guns
in your home?
If yes, are they locked
up & ammo
Have you or any family
members ever been
hurt, insulted, threatened or screamed at?
Name you prefer we use when contacting you (nickname, first, or last with Mr, Mrs, Ms, etc): ________________________________
Country of birth: ____________________________________________
Who lives at home with you: No one Spouse/partner Children _________________________________________________
Pets (what type) ____________________ Other (roommates, extended family, etc) ________________________
Please list your interests, hobbies, group involvement, volunteer work, and/or travel outside of country in the past 6 months:
Revised 7/10/2015 please go to next page Page 5 of 6
Occupation (or prior occupation): _________________________________ Employer: _____________________________________
If you are not currently working, you are: retired unemployed on a leave of absence disabled homemaker
other _______________________
Marital status: single partner married divorced widowed
Spouse/partner’s name: _______________________________
Number of children: _______ Ages (if minors): ___________________ # of grandchildren: _______ # of great grandchildren: ______
Education: high school or GED trade school college graduate school other ____________
Please check any of the following forms you have completed:
Advance Directive for Health Care (ADHC)
Durable Power of Attorney (DPA) for healthcare decisions
Living Will
POLST (Physician Orders for Life Sustaining Therapy)
Know about these or have the forms but have not completed them
Don’t know what these are
Total number of pregnancies: _____ Number of births: _____ Number of miscarriages: _____ Number of abortions: ______
Age at beginning of periods (menstruation): _________
Age at end of periods (menopause/hysterectomy): _________ Not applicable
Do you have concerns about your periods or menopause you’d like to discuss? No Yes
If you are having periods, how often do they occur? Every _______ days. How long do they last? ______ days.
Thank-you for taking the time to complete this form!
Revised 7/10/2015 Page 6 of 6