Check illnesses that have occurred in blood
relatives:
Diabetes High Blood Pressure Stroke
Cancer
Heart Disease Kidney disease
Check conditions you have or have had in
the past:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
AIDS/HIV
Allergies
Amenia
Arthritis
Bleeding Disorders
Breast Lump
Cancer
Diabetes
Emphysema
Epilepsy
Heart disease
Hepatitis
Multiple Sclerosis
Polio
Pheumatic Fever
Seizures
Stroke
Thyroid disorders
Veneral disease
Check symptoms you have or have had in
the last year:
General symptoms
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Depression
Difficulty in focusing
Dizziness
Easily startled
Excessive worry
Excessive anger
Ex cessive fear
Fatigue/tiredness
Fever
Loss of sleep/poor sleep
Loss or gain of weight
Nervousness/irritability
Overwhelmed by life
Sweat easily
Night sweats
Cold hands or feet
Poor memory
Muscle/joints/bones
o
o
o
o
o
o
o
o
o
o
tremors/cramps
swollen joints
Pain, weakness, numbness in:
Neck
Back
Shoulders/arms
Hands/fingers
Hips/legs
Feet/toes
Other________________________
Head/eyes/ear/nose/throat
o
o
o
o
o
o
o
o
o
o
o
o
o
Headache
Facial pain
TMJ
Blurred or failing vision
Eye pain/itching
Decreased night vision
Ringing in ears
Earache
Loss of hearing
Nose bleeds
Sinus problems
Mouth sores
Hoarseness
Gum/teeth problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Bad taste in mouth
Dry mouth
Recurrent sore throat
Enlarged glands
Skin / hair
Acne
Boils
Brittle hair/nails
Bruise easily
Dandruff
Dry skin
Eczema
Hair loss
Itching/rash
Psoriasis
Sensitive skin
Sores that won’t heal
Respiratory
o
Cough
o
o
o
o
o
o
Asthma/wheezing
Shortness or breath
Tightness in the chest
Difficulty breathing
Frequent colds
Hay fever
Cardiocavascular
o
o
o
o
o
o
o
o
Chest pain
Hardening of arteries
High or low blood pressure
Fainting
Poor circulation
Previous heart attack
Rapid/irregular heart beat
Swelling of ankles
Gastrointestinal
o
o
o
o
o
o
o
o
o
o
o
Acid regurgitation
Belching . gas or bloating
Colon trouble
Constipation
Diarrhea
Difficulty swallowing
Distention of abdomen
Excessive hunger
Gallbladder trouble
Heartburn
Hemorrhoids
o
o
o
o
Menopsausal symptoms
PMS
Previous miscarriage
Scanty menstrual flow
o
o
o
o
o
o
o
Indigestion
IBS
Nausea
Pain over stomach
Poor appetite
Ulcers
Vomiting
Genito/urinary
o
o
o
o
o
o
o
Blood//pus in urine
Frequent urination
Inability to control urine
Kidney infection/stones
Lowered libido
Painful urination
Chronic urinary tract infections
FOR MEN ONLY
o
o
o
Erection difficulties
Penis discharge
Prostate trouble
FOR WOMEN ONLY
o
o
o
o
o
Bleeding between periods
Clots in menses
Excessive menstrual flow
Menstrual pain
Irregular cycle
Could you be pregnant?_________________
Is there anything else you would like to discuss?
____________________________________________________________________________
____________________________________________________________________________
Signature
The information on this form is true to the best of my knowledge
_____________________________________________Date____________________________