Have you had any of the following within the last 6 months?
GENERAL
Tire easily, weakness
Marked weight change
Night sweats
Persistent fever
YES
YES
YES
YES
NO
NO
NO
NO
SKIN
Eruptions/rash
Change in color
Change in hair
Change in nails
YES
YES
YES
YES
NO
NO
NO
NO
EYES
Trouble seeing
Eye pain
Inflamed eyes
Double vision
YES
YES
YES
YES
NO
NO
NO
NO
EARS
Loss of hearing
Ringing in ears
Drainage
YES
YES
YES
NO
NO
NO
NOSE
Loss of smell
Frequent colds
Obstruction
Excess drainage
Nosebleeds
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
MOUTH
Sore gums
Sore tongue
Dental problems
YES
YES
YES
NO
NO
NO
HEART/LUNGS
Persistent cough
YES
Sputum (phlegm)
YES
Bloody sputum
YES
Wheezing
YES
Chest pain/discomfort YES
Pain with breathing
YES
Shortness of breath
YES
Difficulty breathing while
lying down
YES
Swelling of ankles
YES
Blue-tinged lips/nails
YES
High blood pressure
YES
Palpitations
YES
DIGESTIVE SYSTEM
Change in appetite
Difficulty swallowing
Heartburn
Abdominal distress
Belching/excess gas
Bloating
Nausea
Vomiting
Vomiting of blood
Rectal bleeding
Tarry stools
Dark urine
Jaundice
Constipation
Diarrhea
Hemorrhoids
GENITOURINARY
Urinary frequency
Urinary urgency
Unable to hold urine
Pain or burning on
urination
Blood in urine
Impotence
Lack of sex drive
Pain with intercourse
YES
YES
YES
NERVOUS SYSTEM
NO
Headaches
YES
NO
NO
Dizziness
YES
NO
NO
Fainting
YES
NO
NO
Convulsions
YES
NO
NO
Nervousness
YES
NO
NO
Sleeplessness
YES
NO
NO
Depression
YES
NO
Change in sensation
YES
NO
NO
Numbness in fingers
YES
NO
NO
Numbness in toes
YES
NO
NO
Tingling in fingers
YES
NO
NO
Tingling in toes
YES
NO
NO
Memory loss
YES
NO
Poor coordination
YES
NO
Weakness/paralysis
YES
NO
NO
NO
GYN/OB
NO
Age menstruation began ______
NO
Date of last PAP_____________
NO
Number of pregnancies _______
NO
Number of miscarriages_______
NO
Number of births_____________
NO
NO
MISC.
NO
Do you have any other concerns
NO
you would like the physician to
NO
be aware of?
NO
__________________________
NO
__________________________
NO
__________________________
NO
__________________________
__________________________
__________________________
NO
__________________________
NO
__________________________
NO
__________________________
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
THROAT
Postnasal drainage
Soreness
Hoarseness
YES
YES
YES
NO
NO
NO
BREASTS
Lumps
Discharge
YES
YES
NO
NO
ENDOCRINE
Thyroid trouble
Adrenal trouble
Cortisone treatment
Diabetes
YES
YES
YES
YES
NO
NO
NO
NO
Patient Signature
Date
________________________________________
________________________________________
Physician Signature
Date
________________________________________
________________________________________
LOCOMOTOR
Muscle cramps
Muscle weakness
Pain in joints
Swollen joints
Stiffness
Deformity of joints