Date:
Patient Name________________________________Patient ID #____________________________
Please explain each “yes” answer on the back. Indicate if you are having these concerns now or in the past.
SYMPTOM
Alcohol problems
*Allergies To Medications
Anger
Asthma
Back pain
Blackouts
Cancer
Chest pains
Chronic cough
Chronic pain
Clenching/tightness of jaw
Cold hands/feet
Colds/Flu
Colitis
Constipation
Decreased productivity
Diabetes
Diarrhea
Difficulty falling asleep
Difficulty staying asleep
Dizziness/fainting
Don’t like being touched
Drug abuse/dependence
Dry Mouth
Epilepsy or seizures
Excessive sweating
Exhaustion
Eye trouble
Fatigue
Feelings of
inadequacy/Loss of self
esteem
Flushes
Gastrointestinal disease
Glaucoma
Grinding of teeth
Head Injury/Loss of
consciousness
Hear things others don’t
Hearing problems
Heart attack/heart trouble
High blood pressure
Indigestion
Infectious disease
Jaundice/liver disease
Kidney disease
Loss of appetite
Loss of interest or
enjoyment in activities
Low blood pressure
YES
NO
NOT SURE
SYMPTOM
Muscle tension/cramps
Nausea
Nervousness
Neurological disease
Numbness
OB/GYN disorder
Overweight
Pounding heart
Paralysis
Pessimistic attitude
Physical trauma
Prostate problems
Rapid heart beat
Recent weight gain
Recent weight loss
See things others don’t
Sexual difficulties
Sexually transmitted
diseases
Shortness of breath
Sinus congestion
Skin problems
Social withdrawal
Stomach trouble
Stroke
Sugar/albumen in urine
Suicidal thoughts
Suicide attempts
Tearful/crying spells
Thyroid disease
Thyroid trouble
YES
NO
NOT SURE
Tics
Tingling
Tremors
Twitches
Ulcers
Unable to relax
Underweight
Visual disturbances
Vomiting
Watery eyes
Other conditions:
Allergies to Medication:
Date of Most Recent
Labs and What Tests:
Take Herbs:
Date of Last Menstrual
Period:
Height:
Weight:
*Please list all medication allergies here: _____________________________________________________