Comprehensive Adult Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: //_____
• Sex: □ M □ F □ Other Gender Identity: ________________
• Address: _________________ City: _______ State: ___ ZIP: _____
• Phone: _____________ Email: _________________

Chief Complaint

Reason for today's visit: _________________________________

Past Medical History

Please check all that apply:

Cardiovascular

□ Hypertension □ Heart Disease □ High Cholesterol □ Irregular Heartbeat

Respiratory

□ Asthma □ COPD □ Sleep Apnea

Endocrine

□ Diabetes Type 1 □ Diabetes Type 2 □ Thyroid Disease

Surgical History

Current Medications

Allergies

□ No Known Drug Allergies

Family History

Social History

• Tobacco Use: □ Never □ Former □ Current
• Alcohol Use: □ Never □ Occasional □ Regular
• Exercise: □ None □ Moderate □ Regular

Review of Systems

Please check any current symptoms:

General

□ Fever □ Fatigue □ Weight Changes

Cardiovascular

□ Chest Pain □ Palpitations □ Edema

Immunization History

Certification

I certify that the information provided is complete and accurate.

Signature: _________________ Date: //_____