CONDITION LIST:
PLEASE DO NOT WRITE ON THIS PAGE.
THE INFORMATION HERE IS TO HELP REMIND YOU OF POSSIBLE MEDICAL CONDITIONS.
General health: Weight changes, fatigue, sweats, chills, lymph nodes, swelling,
lumps, sores or discharge anywhere on body, skin problems, easy bruising.
Neck: stiff, pain, tender, glands.
Ears: pain, hearing loss, ringing, hearing aid.
Nose: bleeding, colds, obstruction, septum problem.
Mouth: dental problem, bleeding, sores, sore throat, bad taste.
Eyes: double vision, tearing, blind spots, pain, eyelid droop, blurry, cataracts.
Breathing: asthma, short of breath, cough, blood, TB, COPD, bronchitis.
Heart: chest pain, palpitations, passing out, blood pressure, murmurs, mitral valve
prolapse, varicose veins, Reynaud’s, anemia, bleeding problems or clots.
Immune: frequent infections, constant colds or flus.
Genital: hernia, pain, STDs, HIV, painful intercourse, erectile dysfunction,
pregnancy or planning, breast, tenderness. Abnormal bleeding or periods.
GI: appetite, abdominal pain, GERD, nausea, vomiting, jaundice, hepatitis A/B/C,
constipation, diarrhea, hemorrhoids, change in bowel habits or change in stools.
Urinary: urgency, frequency, pain, blood, stones, infections, kidney, retention
(can’t go), incontinence (can’t hold), discharge.
Endocrine: diabetes, thyroid, infertility, acne, goiter, heat/cold intolerance,
tremor, palpitations.
Neuro: stroke, seizure, Alzheimers, Parkinsons, migraine, meningitis, MS, brain
injury, neuropathy, muscles, spinal cord, weakness, cramps, atrophy.
Mood: nervous, anxiety, mood swings, depression, crying, sleeping, libido,
suicidal thoughts, suicide attempts, panic.
Social: alcohol abuse, smoking, drug abuse.
Emergency issues: The worst headache of your entire life right now? Seeing
double? Unable to speak or swallow properly? Part of body gone weak, paralyzed,
numb or can’t feel? Problem controlling bladder or bowels? Losing consciousness,
pass out or falling? Everything spinning around? New or sudden pain?
REMEMBER: Any of these above problems in red is a neurological RED FLAG and
may signal a serious emergency. If any of these occur at home, please immediately
call 911 or go to the nearest emergency room!