If yes, please provide name of physician and/or practice Review of Symptoms: General Gastrointestinal Muscle/Joint/Bone/Pain Anxiety Abdominal pain or cramps Neck Legs Chronic Pain Bowel changes Shoulder Knees Dizziness Nausea Back Ankles Headache Poor Appetite Arms Feet Loss of Sleep Vomiting Hands Arthritis Loss of weight Hips Muscle Cramps Psychiatric Cardiovascular Neurological Anxiety Cardiac Palpitations Fainting Depression High Blood Pressure Headache Disturbing feelings Irregular heartbeat Numbness Panic Attack Rapid Heartbeat Seizures Restlessness Neuropathy Current Conditions Aids Alcoholism Chemical Dependency Anorexia Anxiety Arthritis Cancer Chemical Dependency Chronic Pain HIV Positive Depression Epilepsy Fibromyalgia Glaucoma Insomnia Migraine Headaches Current Diagnoses: ____________________________________________________________________________________ Medications Over the counter_____________________________________________________________________________
If yes, please provide name of physician and/or practice Review of Symptoms: General Gastrointestinal Muscle/Joint/Bone/Pain Anxiety Abdominal pain or cramps Neck Legs Chronic Pain Bowel changes Shoulder Knees Dizziness Nausea Back Ankles Headache Poor Appetite Arms Feet Loss of Sleep Vomiting Hands Arthritis Loss of weight Hips Muscle Cramps Psychiatric Cardiovascular Neurological Anxiety Cardiac Palpitations Fainting Depression High Blood Pressure Headache Disturbing feelings Irregular heartbeat Numbness Panic Attack Rapid Heartbeat Seizures Restlessness Neuropathy Current Conditions Aids Alcoholism Chemical Dependency Anorexia Anxiety Arthritis Cancer Chemical Dependency Chronic Pain HIV Positive Depression Epilepsy Fibromyalgia Glaucoma Insomnia Migraine Headaches Current Diagnoses: ____________________________________________________________________________________ Medications Over the counter_____________________________________________________________________________