Primary Care Physician: _____________________
Height:________ Date of last FLU shot: ________
Marital Status: M / S / W / D
Reason for visit / concerns: _____________________
___________________________________________
___________________________________________
Pulmonary:
YES / NO shortness of breath (dyspnea)
YES / NO shortness of breath when sleeping (PND)
YES / NO shortness of breath when lying flat (orthopnea)
YES / NO cough
YES / NO cough up blood (hemoptysis)
YES / NO wheezing
PLEASE READ QUESTIONS AND CIRCLE YES OR NO
Systemic:
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
feeling poorly (malaise)
fever
chills
night sweats
recent weight change
Head:
YES / NO headache
YES / NO facial pain
YES / NO sinus pain
Neck:
YES / NO neck pain
YES / NO neck stiffness
YES / NO lump or swelling in the neck
Eyes:
YES / NO
YES / NO
YES / NO
YES / NO
vision problems
itching of the eyes
eye pain
sensitive to light (photophobia)
Otolaryngeal:
YES / NO hearing loss
YES / NO earache
YES / NO ringing in the ear (tinnitus)
YES / NO nasal discharge
YES / NO nose bleeds (epistaxis)
YES / NO hoarseness
YES / NO sore throat
YES / NO bleeding gums
YES / NO mouth sores
Breasts:
YES / NO breast lump
YES / NO nipple discharge
YES / NO pain in breast
Cardiovascular:
YES / NO chest pain or discomfort
YES / NO palpitations
YES / NO fast heart rate
YES / NO slow heart rate
YES / NO leg pain when exercise
YES / NO cold hands or feet
Gastrointestinal:
YES / NO change of appetite
YES / NO difficulty swallowing (dysphagia)
YES / NO heartburn
YES / NO nausea
YES / NO vomiting
YES / NO abdominal pain
YES / NO black or bloody stools (melena)
YES / NO diarrhea
Genitourinary:
YES / NO blood in urine (hematuria)
YES / NO increase in urinary frequency
YES / NO painful urination (dysuria)
Endocrine:
YES / NO excessive thirst (polydipsia)
YES / NO excessive sweating
YES / NO any swelling (edema) if so where ___________
Musculoskeletal:
YES / NO muscle aches
YES / NO localized joint pain
YES / NO localized joint stiffness
Neurological:
YES / NO dizziness
YES / NO vertigo
YES / NO fainting
YES / NO motor disturbances
YES / NO sensory disturbances
Psychological:
YES / NO anxiety
YES / NO depression
YES / NO sleep disturbances
Skin:
YES / NO itchy skin (pruritus)
YES / NO skin lesions
YES / NO rash.
Do you smoke YES / NO
Have you ever smoked YES / NO
Do you use alcohol in moderation YES / NO
Do you use recreational drugs YES / NO
Caffeine use YES / NO