HEALTH QUESTIONNAIRE (Continued)
ARE YOU EXPERIENCING ANY OF THE FOLLOWING:
CONSTITUTIONAL SYMPTOMS
GENITOURINARY
Unexplained weight gain or loss …………….
Fever or chills ………………………………………..
Night sweats/Hot flashes ……………………….
Fatigue …………………………………………………..
Yes
Yes
Yes
Yes
No
No
No
No
HEMATOLOGIC/LYMPHATIC
Bleeding or bruising tendency ………………. Yes
Anemia …………………………………………………. Yes
No
No
EYES
Blurred or double vision …………………………. Yes
No
EARS/NOSE/MOUTH/THROAT
Hearing loss or ringing ………………………….
Earaches or drainage …………………………….
Chronic sinus problem or rhinitis ………….
Recurrent nose bleeds ………………………….
Bleeding gums ………………………………………
Sore throat or voice change (hoarseness).
Hay fever ……………………………………………….
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CARDIOVASCULAR
Heart trouble ………………………………………… Yes
Chest pain or angina pectoris ……………….. Yes
Palpitation (fast or irregular heart beat) .. Yes
Shortness of breath while walk/lying flat . Yes
Swelling of feet, ankles or hands …………… Yes
High blood pressure ………………………………. Yes
No
No
No
No
No
No
RESPIRATORY
Chronic or frequent coughs …………………..
Spitting up blood …………………………………..
Shortness of breath ………………………………
Asthma or wheezing ……………………………..
No
No
No
No
Yes
Yes
Yes
Yes
GASTROINTESTINAL
Loss of appetite ……………………………………. Yes
Change in bowel movements ………………. Yes
Nausea or vomiting ……………………………… Yes
Frequent diarrhea ……………………………….. Yes
Painful bowel movements or constip……. Yes
Rectal bleeding or blood in stool …………. Yes
Abdominal pain or heartburn ………………. Yes
Peptic ulcer (stomach or duodenal) …….. Yes
Trouble swallowing ……………………………… Yes
Physician Initials: ______________
Date: ______________
No
No
No
No
No
No
No
No
No
Frequent urination ……………………………Yes
Burning or painful urination ……………..Yes
Blood in urine ……………………………………Yes
Urination at night (> 1/night)? ………….Yes
Incontinence or dribbling ………………… Yes
Decrease in urine stream ………………… Yes
Kidney stones ………………………………….. Yes
No
No
No
No
No
No
No
Sexual difficulty ……………………………….. Yes
Slow to start/stop urination …………….. Yes
No
No
MUSCULOSKELETAL
Joint pain ……………………………………….. Yes
Joint stiffness or swelling ……………….. Yes
Back pain ……………………………………….. Yes
No
No
No
INTEGUMENTARY (skin, breast)
Rash or itching ………………………………... Yes
Breast pain ……………………………………… Yes
Breast lump …………………………………….. Yes
Breast discharge ……………………………… Yes
No
No
No
No
NEUROLOGICAL
Frequent or recurring headaches …… Yes
Lightheaded or dizzy ………………………. Yes
Convulsions or seizures ………………….. Yes
Numbness or tingling sensations ……. Yes
Paralysis …………………………………………. Yes
Memory loss or confusion ………………. Yes
No
No
No
No
No
No
ENDOCRINE
Thyroid disease ………………………………. Yes
Diabetes …………………………………………. Yes
Other glandular or hormone problem Yes
No
No
No
OTHER
Nervousness …………………………………… Yes
Depression/Anxiety/Panic ……………… Yes
Insomnia ……………………………………….. Yes
No
No
No
Other concerns not noted above:
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