Chiricahua Community Health Centers, Inc.
Adult Personal Medical Health History
Name Birth Date: Today’s Date
Occupation Age Marital Status
Please circle below indicating if you have ever had any of the following problems:
Rheumatic Fever Gall Bladder Probs. Uterine Problems Wear Contacts Tubes/Ovary Probs.
Lung Disease Liver Problems Thyroid Problems German Measles Varicose Veins
Herpes Genital Warts Gonorrhea
Please circle any of the following problems that you have had within the last month.
Head/Neck Digestive Musculoskeletal Eyes Skin
Headaches Heartburn Aching muscles Wear glasses Skin problems
Neck pain Bloating Aching joints Blurry vision Itching or burning
Neck lumps Belching Swollen joints Change in vision Easy bleeding
Neck swelling Nausea Back pain Double vision Easy bruising
Ears Vomiting blood Shoulder pain Seeing halos Mouth
Trouble hearing Trouble swallowing Painful feet Eye pain or itching Swollen gums or Jaw
Earaches Constipation Neurological Watery eyes Sores
Drainage Diarrhea Fainting Urinary Dental problems
Drainage Black/gray stools Numbness Urinating at night Mood
Buzzing Pain in rectum Seizures More frequently Nervous
Nose Rectal bleeding Trouble writing Trouble holding urine Suicidal
Congestion Throat Shaky hands Burning or pain Depressed
Runny nose Sore throat General Bloody urine Stressed out
Sinus infections Swollen or large Always too cold or Trouble starting to Hitting spouse or
Sneezing tonsils too hot urinate children
Nosebleeds Hoarse voice Change in weight Urgency Loosing temper
Respiratory Cardiovascular Loss of appetite Male Genital Sexual problems
Wheezing Chest pains Always hungry Weak urine stream Female Genital
Cough Short of breath Always thirsty Burning or discharge Lumps in breast
Phlegm Racing heartbeat Always tired Lump in testicle Pain with sex
Coughed up Swollen feet or legs Trouble sleeping Painful testicle No interest in sex
blood Cramps in legs Trouble exercising Sores on penis Vaginal itching or
Bronchitis Dizzy Swelling in armpits discharge
Pneumonia or groin
Asthma
Yes No
Are you sexually active?
If yes: Men Women Both
Have you ever been kicked, punched or hit by your sexual
partner?
Do you feel safe at home?
Have you ever been emotionally abused by your current partner
Comments:
Revised: 05/2006 CQI team & Provider Staff