Adult New Patient History
Name:
______
Date of Birth:
Date:
For Internal Use Only:
Does patient need a translator?
 Yes  No
WHC Employee Initial ____________
WHC Employee Initial ____________
Does patient need assistance with reading or writing?  Yes  No
Please list the other doctors you see:
Please list any allergies:
Past Medical History
Acid Reflux
Anxiety
Yes No
Yes No
Yes No
Seizure Disorder
Stroke
Seasonal Allergies
Substance Abuse/Alcoholism
Thyroid Problem
Tuberculosis
High Blood Pressure
High Cholesterol
Enlarged Prostate
Heart Attack
Heart Valve Problem
Hepatitis
Asthma
Bipolar Disorder
Blood Clot (DVT/PE)
Cancer
Chronic Pain
COPD
Coronary Artery Disease
Crohn’s Dis/Ulcerative Colitis
Depression
Hemophilia (Free Bleeder)
Kidney Disease
HIV/AIDS
Migraines
Peripheral Artery Disease
Rheumatoid Disease
Other:
Other:
Other:
Other:
Other:
Other:
Diabetes
Surgical History
Year
Year
 Appendix Removed
 Back Surgery
 Bladder Surgery
 Cataract
 Hernia Repair (Type: _________________)
 Hysterectomy: Partial or Complete
 Orthopedic Surgery
 Tonsils Removed
 Tubal Ligation
 Vasectomy
 Other:
 Other:
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C Section
Ear Tubes
Heart Catheterization:
Gallbladder Removal
 Heart Bypass
 Other:
Family History: Check which family members have had the following
None
Mother
Father
Sister
Brother
Other
Cancer
Type: _________________
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High Cholesterol
Diabetes Mellitus
Heart Disease
Hypertension
Mental Illness
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Stroke
Substance Abuse/Alcoholism
Other
(specify): _________________

 
Social History
 Married
 Single
 Widow
 Divorced
Do you have children?  Yes  No Number of Children ____ Do you have custody?  Yes  No
Job Occupation ___________________ _________________________________  Retired
 Disabled If disabled, please list reason: _____________________________________________________________
Tobacco Use  None  Quit (date) _____ Still use:  Cigarettes  Smokeless/Chew  Cigars  Pipe
Check the amount of tobacco you use(d) each day.  ½ pack/can
How many years did/have you smoked? _____  2 packs/cans
 1 pack/can
 More
Alcohol Use  None (A drink is 1 shot of liquor, 1 glass of wine, or 1 bottle/can of beer.)
 Less than 1 drink/month  1-15 drinks/month  4-14 drinks/week  More than 2 drinks/day
Drug Use
 Yes  No  Quit (date) _____
If yes, what do you use regularly? _____________
HIV/AIDS Screening  Yes  No
If yes, where and when? __________________________________________
Health Maintenance
Do you wear seatbelts?
 Always
 Sometimes
 Yes  No
Date of your last pneumonia shot: __________
Date of your last shingles shot:
Date of your last eye exam:
 Never
Have you seen a dentist in the past year?
Date of your last colonoscopy: __________
Date of your last tetanus shot: __________
__________
__________
Date of your last flu shot:
__________
Women ONLY:
Date of your last mammogram: __________
Date of your last pap smear:
__________
Number of pregnancies?
__________
Current Medications
 None
*If you need more lines, please request another form.
Name of Medication
Strength (mg)
How Often
Reason for Medication
Advanced Directives/Living Wills:
Do you have an advanced directive or a living will?
If yes, please give a copy to front desk.
If no, would you like more information?
 Yes  No
 Yes  No
Name of Person Completing Form:
Patient Signature: