Please any relevant symptoms or conditions you have or previously had: Gastrointestinal Cardiovascular Ear, Eye, Nose & Throat General Allergies Pain High blood pressure Impaired hearing □ □Abdominal □ □ Depression Bloody stool Low blood pressure Ear ache □ □ □ □ Dizziness Colitis/Crohn’s of arteries Ringing of the ears □ □ □Hardening □ Fainting Constipation Irregular pulse infection □ □ □ □ Fatigue Diarrhea Pain over heart Sore throat □ □ □ □ Headaches or migraines Change in appetite Poor circulation Vision problems □ □ □ □ Loss of sleep Hernia Change in beat Frequent colds □ □ □ □ Tremors Liver trouble Swelling of ankles Stuffiness □ □ □ □ Weight loss/gain Nausea Nose bleeds □ □ □ Seizures Vomiting Respiratory □ □ Memory loss Chest pain Other conditions: □ □ Genitourinary Chronic cough □ □Anemia Muscle/Joint Bladder infection Difficulty breathing Arteriosclerosis □ □ □ Arthritis/rheumatism Blood in urine Shortness of breath Asthma □ □ □ □ Bursitis Kidney infection Spitting up blood Cancer □ □ □ □ Foot trouble Kidney stones Diabetes □ □ □ Muscle weakness Prostate trouble Skin Edema □ □ □ Low back pain Pus in urine Bruise easily Epilepsy □ □ □ □ Neck pain Urination Hives/Allergies Goiter □ □ □ Mid back pain Overnight >Twice Rash Gout □ □ □ □ Joint pain > 8x in 24hrs Varicose veins Heart burn □ □ □ □ Numbness or tingling Decreased flow Acne or boils Heart disease □ □ □ □ Painful urination Itching High cholesterol □ □ □ Urgency to urinate Eczema HIV/AIDS □ □ □ WOMEN ONLY Multiple Sclerosis □ Congested breasts Menstrual flow Birth control method: _______ Pace maker □ □ Hot flashes Irreg. Pain Prior miscarriage? Stroke □ □Reg □ □ □Yes □No □ Lumps in breast Date last period:____ Date of last PAP exam: _______ Osteoporosis □ □ Menopause Are you pregnant? No Date of last mammogram:______ Thyroid disease □ □Yes □ □ Vaginal discharge If yes, how many months? ___ □ □Normal □Abnormal # of children you have _____
Please any relevant symptoms or conditions you have or previously had: General Gastrointestinal Cardiovascular Ear, Eye, Nose & Throat □ Allergies □Abdominal Pain □ High blood pressure □ Impaired hearing □ Depression □ Bloody stool □ Low blood pressure □ Ear ache □ Dizziness □ Colitis/Crohn’s □Hardening of arteries □ Ringing of the ears □ Fainting □ Constipation □ Irregular pulse □ infection □ Fatigue □ Diarrhea □ Pain over heart □ Sore throat □ Headaches or migraines □ Change in appetite □ Poor circulation □ Vision problems □ Loss of sleep □ Hernia □ Change in beat □ Frequent colds □ Tremors □ Liver trouble □ Swelling of ankles □ Stuffiness □ Weight loss/gain □ Nausea □ Nose bleeds □ Seizures □ Vomiting Respiratory □ Memory loss □ Chest pain Other conditions: Genitourinary □ Chronic cough □Anemia Muscle/Joint □ Bladder infection □ Difficulty breathing □ Arteriosclerosis □ Arthritis/rheumatism □ Blood in urine □ Shortness of breath □ Asthma □ Bursitis □ Kidney infection □ Spitting up blood □ Cancer □ Foot trouble □ Kidney stones □ Diabetes □ Muscle weakness □ Prostate trouble Skin □ Edema □ Low back pain □ Pus in urine □ Bruise easily □ Epilepsy □ Neck pain Urination □ Hives/Allergies □ Goiter □ Mid back pain □ Overnight >Twice □ Rash □ Gout □ Joint pain □ > 8x in 24hrs □ Varicose veins □ Heart burn □ Numbness or tingling □ Decreased flow □ Acne or boils □ Heart disease □ Painful urination □ Itching □ High cholesterol □ Urgency to urinate □ Eczema □ HIV/AIDS WOMEN ONLY □ Multiple Sclerosis □ Congested breasts Menstrual flow Birth control method: _______ □ Pace maker □ Hot flashes □Reg □ Irreg. □ Pain Prior miscarriage? □Yes □No □ Stroke □ Lumps in breast Date last period:____ Date of last PAP exam: _______ □ Osteoporosis □ Menopause Are you pregnant? □Yes □ No Date of last mammogram:______ □ Thyroid disease □ Vaginal discharge If yes, how many months? ___ □Normal □Abnormal # of children you have _____
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