X-rays taken? Yes No Date __________________________________ Draw In Your Face Show area(s) of pain or unusual feeling. Mark the areas on this body where you feel the described sensations. Use the appropriate symbols. Mark areas of radiation. Include all affected areas. PAIN Circle area NUMBNESS ^^^^^^^^^^ PINS & NEEDLES 000000000 BURNING xxxxxxxxxx ACHING * * * * * STABBING / / / / / / / TIGHTNESS ######### Have you ever had any of the following? aneurysm allergies pneumonia pleurisy osteoporosis heart conditions asthma diabetes hepatitis V.D. arthritis nervousness psoriasis respiratory conditions anxiety HIV epilepsy fatigue sinus condition cancer polio stroke(s) sleeping difficulty Please check any childhood conditions measles diphtheria chronic illness scarlet fever tubes in ears ear infections chicken pox whooping cough mumps rheumatic fever typhoid fever Habits of Lifestyle Do you smoke? Yes No Do you consume alcohol? Yes No If so, how much? _____________ If so, how much? ____________________________ Do you exercise Yes No Exercise indoor activities _______________________ – Exercise outdoor activities ______________________ – Rate your sleep hours per night 4-6 6-8 8-10 12+
X-rays taken? Yes No Date __________________________________ Draw In Your Face Show area(s) of pain or unusual feeling. Mark the areas on this body where you feel the described sensations. Use the appropriate symbols. Mark areas of radiation. Include all affected areas. PAIN Circle area NUMBNESS ^^^^^^^^^^ PINS & NEEDLES 000000000 BURNING xxxxxxxxxx ACHING * * * * * STABBING / / / / / / / TIGHTNESS ######### Have you ever had any of the following? aneurysm osteoporosis diabetes arthritis respiratory conditions epilepsy cancer stroke(s) allergies heart conditions hepatitis nervousness anxiety fatigue polio sleeping difficulty pneumonia pleurisy asthma V.D. psoriasis HIV sinus condition Please check any childhood conditions measles scarlet fever ear infections mumps diphtheria tubes in ears chicken pox rheumatic fever chronic illness whooping cough typhoid fever Habits of Lifestyle Do you smoke? Yes No Do you consume alcohol? Yes No If so, how much? _____________ If so, how much? ____________________________ Do you exercise Yes No Exercise – indoor activities _______________________ Exercise – outdoor activities ______________________ Rate your sleep hours per night 4-6 6-8 8-10 12+