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									                      FORM 1 - PHA-ADULT MEDICINE, PC - - - --ADULT MEDICAL HISTORY
                          1740 South Street, Philadelphia, PA 19146 – – 215-732-0876
                                        Dr. Shahana Karim, Dr Jon Shapiro, Dr Wilbert Warren
Name:                                 DOB:           (mm/dd/yyy)            Date of Visit:
Main Reason for today’s visit:
 Are you in good general health?        No      Yes                                CHECK ANY OF THE CONDITIONS YOU HAVE HAD.
 List all prescribed and over-the-counter drugs you are taking with doses             Anemia Arthritis       Asthma Blood clots      Chronic
                                                                                   obstructive lung disease Depression     Diabetes Glaucoma
                                                                                      Hay Fever Heart failure Heart disease       High blood
                                                                                   pressure     Kidney disease Peptic ulcers   Reflux     Seizures
                                                                                      Stroke     Thyroid disease  Sexual Transmitted Diseases
 What are you allergic to? Penicillin, sulfa drugs,         x-ray dyes,            Positive TB skin test
  ace inhibitors shell fish   Other substances?                                       Other:
 IMMUNIZATIONS (year you received)                                                 LIST ALL OPERATIONS WITH DATES
 Hepatitis A      Hepatitis B   Pneumonia
 Influenza(flu)      Tetanus    Swine Flu vaccine
 Tetanus & Pertussus (Tdap)
 Measles, Mumps, Rubella (MMR)
 Varicella Vaccine (chickenpox)     Meningitis                                     HAVE YOU BEEN HAVING THE FOLLOWNG?
                                                                                                          (Check the box)
 ENTER THE DATE YOU LAST RECEIVED THESE TEST                                         Abdominal pain        Anxiety symptoms
 Colonoscopy (colon cancer) Glaucoma                                                  Bleeding tendency or excessive bruising
 Mammogram (breast cancer)  PSA (Prostate Cancer)                                     Blood in stool or change in bowel movements
 Dexacan (osteoporosis)     Last Pap Smear                                            Breast lump or nipple discharge Change in vision
                                                                                     Chest pain/tightness/discomfort Cold or heat intolerant
 LIFESTYLES SURVEY                                                                   Concern about sexual function        Constipation
 Do you wear seatbelt? NO YES                                                        Coughing up blood        Diarrhea     Difficulty urinating
 Do you wear a bike helmet? NO YES                                                   Discharge: vagina or penis        Dizziness
 Do you smoke? NO YES If yes, how many cigs per day?                                 Frequent urination      Headaches (frequent)
 Do you drink alcohol? NO YES. How many per week?                                    Increased thirst or Appetite      Muscle or Joint pain
 Do you drink coffee or tea? If yes, how much: NO YES                                Indigestion or heartburn
 Is there a gun at home? NO YES                                                      Irregular heart beat (fast, skipped beats)    Insomnia
 If yes, is it out of children’s reach and unloaded?   NO YES                        Losing control of urine Lost interest in things or feel
 Do you use recreational drugs? NO             YES                                 hopeless
 Have you used needles to inject drugs?        NO YES                                Low back pain       Nausea or vomiting
 Are you sexually active? NO YES                                                     Neck pain      Persistent cough      Poor appetite
 Current sex partners is/are       Male     Female                                   Rash      Recent fevers/sweats       Shortness of breath
 Birth Control Method is                                                             Swollen legs or ankles       Trouble swallowing
 Do you wish to be tested for HIV? NO YES                                            Unexplained weight loss or gain       “yellow Jaundice”
 Have you worked with asbestos or other hazardous materials? NO             YES
 Do you exercise regularly? NO YES                                                 WOMEN ONLY enter dates as (m/d/yyyy)
 Do you have a Living Will or Power of Attorney NO        YES                      Age period began         Your last period?
 Is violence a concern in your home? NO            YES                             How many pregnancies have you had?
 My Job is:                                                                        How many deliveries?      Miscarriages?    Abortions?
                                                                                   Do you have irregular menses? NO         YES
 FAMILY HISTORY                                                                    Do you have pelvic pain? NO        YES
                     Mom Dad Sibling Grandparents Aunt Uncle
 Alcoholism                                                                        Physician Use Only (Comments)
 Heart Disease
 High cholesterol
 High blood pressure
 Bleeding Disorders

Physician Use: _________________________________________________________________________________

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