Patient Name: __________________________________
Date: ____________________
Please circle any symptoms that you or your child has experienced:
General
Fevers
Chills
Sweats
Fatigue
Weight loss
Musculoskeletal
Back pain/muscle pain
Joint swelling
Joint pain
Cramping
Weakness
Genitourinary
Frequency of urination
Pain with urination
Blood in urine
Discharge
Eyes
Redness
Discharge
Eye pain
Itchy
Watery
Vision loss
Irritation
Dryness
Nose
Congestion
Runny nose
Post nasal drip
Nose bleeds
Itching
Sneezing
Gastrointestinal
Heartburn
Nausea
Vomiting
Diarrhea
Difficulty swallowing
Abdominal pain
Bloody stools
Ears
Earache
Drainage
Ringing in ear
Decreased hearing
Fullness
Itching
Throat
Hoarseness
Throat fullness
Sore throat
Throat clearing/drainage
Itching
Throat swelling
Skin
Swelling
Hives
Rash
Itching
Dryness
Bruising
Eczema
Mental Health
Depression
Anxiety
Behavioral changes
Hyperactivity
Cardio
Chest pains
Palpitations
Passing out
High blood pressure
Neurological
Headache
Dizziness
Seizures
Memory loss
Endocrine
Intolerance to Hot and Cold
Facial flushing
Increased thirst
Respiratory
Cough
Chest tightness
Wheezing
Shortness of breath
Sputum Production
Allergy/Immunology
Recurrent infections
Insect sting allergy
Food allergy