ADULT HEALTH HISTORY
WESTERN WAKE WELLNESS, PLLC
Patient Name:
*
First Name
Last Name
Birth Date:
*
-
Month
-
Day
Year
Date
Age:
*
Today's Date:
-
Month
-
Day
Year
Name I would like to be called:
My pharmacy is:
PAST MEDICAL HISTORY
Rows
Past Problem
Current Problem
N/A
Diabetics
Hypertension
High cholesterol
Heart attack or angina
Palpitations or arrhythmia
Atrial fibrillation
Congestive heart failure
Heart murmur
Emphysema, chronic bronchiolitis
Asthma
Pneumonia
Nasal Alleries
Problems with eyes or vision
Problems with ears or hearing
Osteoporosis or osteopenia
Arthritis
Mental illness
Addiction issues
Cancer
Thyroid or endocrine
Kidney Disease
Liver Disease
Bowel/Digestive problem
Gastroesophageal reflux
Stomach ulcer
Anemia or Bleeding disorder
Blood transfusion
Headaches
Stroke
Seizures or epilepsy
Sleep problems; snoring
Obesity, overweight
Skin problems (ache, eczema)
Frequent Urinary tract infection
Breast problem
Problem with menstrual cycle
Prostate problem
Sexually transmitted infection
Fracture or broken bones
Surgical History
Rows
Year
Heart surgery
Carotid artery surgery
Vascular surgery/stent
Abdominal aneurysm repair
Tonsillectomy
Wisdom teeth removed
Cholecystectomy (Gallbladder)
Appendectomy
Hysterectomy
Cesarean section
D&C
Breast surgery
Prostate cancer surgery
Hernia repair
Hemorrhoidectomy
Cataract Surgery (Right)
Cataract Surgery (Left)
LASIK
Spine Surgery (Neck)
Spine surgery (Back)
Joint replacement (Knee)
Joint Replacement (Hip)
Joint Replacement (Shoulder)
Joint Replacement (Right)
Joint Replacement (Left)
GYNECOLOGIC HISTORY
Birth Control Type:
Menopause Age:
Menstrual flow
Regular
Irregular
Pain/cramps
First day of last period
-
Month
-
Day
Year
Days of flow:
Length of cycle:
Number of Pregnancies:
Number of Miscarriages
Number of Full-term deliveries
Number of Pre-term deliveries
Did you have diabetes during any of your pregnancies
Yes
No
SOCIAL HISTORY
Please check all that apply
Sex at birth:
Male
Female
Occupation:
Concerns:
Stress
Hazardous substances
Lifting Heavy Objects
Tobacco Use:
Never
Secondhand Smoke
Current
Other
If current, how many packs per day and how many years?
Illicit Drug Use
No
Past
Current
Alcohol Use:
No
Yes
Caffeine Use
No
Yes
Coffee
Soda
Tea
Diet pills or supplements
How many people live in your household?
Who lives with you?
Spouse
Children
Parents
Other
How often do you exercise?
None
1-2x weekly
3-5x weekly
Every day
Exercise doing what?
Do you have children?
No
Yes
If so, how many?
Do you have a Healthcare POA or Living Will?
No
Yes
HEALTH MAINTENANCE & PREVENTION
Rows
Yes
No
Date
Tetanus vaccine/TDap
Pneumonia vaccine
Influenza vaccine
Shingles vaccine
Hepatitis vaccine A
Hepatitis vaccine B
Gardasil (HPV) vaccine
Pap smear/pelvic exam
Mammogram
Bone density
Colonoscopy
Prostate exam & PSA blood test
Chest X-ray
COVID-19 Vaccine
COVID-19 Vaccine 2nd Shot
FAMILY HISTORY
Are there any known genetic disorders in your family?
Yes
No
Rows
Living
Age
Major Medical Problems, or Cause of Death
Father
Mother
Parental grandfather
Parental grandmother
Maternal grandfather
Maternal grandmother
Siblings
Children
Has anyone in your family ever been diagnosed with any of the following conditions:
Diabetes
Hypertension
Heart Attack
Stroke
Thalassemia
Sickle Cell Anemia
Thyroid Disease
Pituitary Disease
Crohn's Disease/Colitis
Celiac Disease
Asthma or allergies
Cataract or glaucoma
Depression
Anxiety
Mental Illness
Drug or Alcohol Abuse
Liver or Kidney Disease
Dementia/Alzheimers
Obesity
Osteoporosis
Arthritis
Blood clots
Bleeding disorder
Epilepsy/seizures
Breast Cancer
Ovarian Cancer
Prostate Cancer
Colon Cancer
Other
If other cancer, list here
Medical or Food Allergies
Medications
Hospital Admissions
SPECIALTY PROVIDERS
To help us coordinate your care, please list any medical providers you see outside this practice:
Cardiology
Pulmonology
OB/Gynecology
Urology
Endocrinology
Dermatology
Nephrology
Gastroenterology
Neurology
Pain Specialist
ENT/Otolaryngology
Allergy/Immunology
Orthopedics
Rheumatology
Hematology/Oncology
Infectious Disease
Podiarist
Ophthalmology/Optometry
Psychiatrist/Psychologist
Surgeon
Are there any religious or cultural factors that you would like us to take into account when planning your healthcare?
Yes
No
Please share anything else with us that we need to know to best care for you.
Submit
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