CARDIOVASCULAR YES NO GENITOURINARY YES NO Chest pain Blood in urine Heart Attack Burning or painful urination Heart trouble Frequent urination Heart valve disease Kidney Stones High pressure Menstrual problems Palpitations Prostate disease Rheumatic fever Sexually transmitted disease Shortness of breath-lying Shortness of breath-walking HEMATOLOGIC/LYMPHATIC YES NO Swelling of feet, ankles, or hands Anemia Bleeding or bruising easily Cancer (area) ________________ EARS, NOSE, MOUTH, THROAT YES NO Bad breath/taste HIV/AIDS Bleeding gums Leukemia Chronic sinus problems Lymphoma Ear infections/drainage Phlebitis/blood clots Hearing loss or tingling Sickle cell Hoarseness Slow to heal after cuts Mouth sores Nose bleeds MISCULOSKELETAL YES NO Swollen Glands in neck Arthritis Back Pain ENDOCRINE YES NO Difficulty in walking Diabetes Joint pain Excessive thirst or urination Joint stiffness or swelling Glandular or hormone problem Multiple sclerosis Thyroid disease Muscle pain or cramps Muscular dystrophy Weakness of muscles or joints EYES YES NO Blurred/double vision Eye disease or injury NEUROLOGICAL YES NO Eye infection Convulsions or seizures Frequent/recurring headaches Glaucoma Head injury GASTROINTESTINAL YES NO Light-headed or dizzy Abdominal pain Migraines Blood in stool Numbness or tingling sensation Change in bowel movements Paralysis Cirrhosis Sleep apnea Constipation Difficult or painful swallowing Frequent diarrhea PSYCHIATRIC YES NO Heartburn Anxiety Hemorrhoids Depression Hepatitis Memory loss or confusion Loss of appetite Nervousness Nausea or vomiting Suicidal Pancreatitis Rectal bleeding RESPIRATORY YES NO Yellow jaundice Asthma or wheezing Bronchitis GENERAL YES NO Chronic or frequent cough Emphysema Fatigue/Malaise Shortness of breath More sensitive to hot/cold Spitting up blood Unexplained weight loss/gain Tuberculosis SKIN YES NO VASCULAR YES NO Change in hair or nails Discoloration of extremities Change in skin color Leg Pain Hives Leg swelling Rash or itching Varicose veins
CARDIOVASCULAR YES NO Chest pain Heart Attack Heart trouble Heart valve disease High pressure Palpitations Rheumatic fever Shortness of breath-lying Shortness of breath-walking Swelling of feet, ankles, or hands EARS, NOSE, MOUTH, THROAT YES NO Bad breath/taste Bleeding gums Chronic sinus problems Ear infections/drainage Hearing loss or tingling Hoarseness Mouth sores Nose bleeds Swollen Glands in neck ENDOCRINE YES NO Diabetes Excessive thirst or urination Glandular or hormone problem Thyroid disease EYES YES NO Blurred/double vision Eye disease or injury Eye infection Glaucoma GASTROINTESTINAL YES NO Abdominal pain Blood in stool Change in bowel movements Cirrhosis Constipation Difficult or painful swallowing Frequent diarrhea Heartburn Hemorrhoids Hepatitis Loss of appetite Nausea or vomiting Pancreatitis Rectal bleeding Yellow jaundice GENERAL YES NO Fatigue/Malaise More sensitive to hot/cold Unexplained weight loss/gain SKIN YES NO Change in hair or nails Change in skin color Hives Rash or itching GENITOURINARY YES NO Blood in urine Burning or painful urination Frequent urination Kidney Stones Menstrual problems Prostate disease Sexually transmitted disease HEMATOLOGIC/LYMPHATIC YES NO Anemia Bleeding or bruising easily Cancer (area) ________________ HIV/AIDS Leukemia Lymphoma Phlebitis/blood clots Sickle cell Slow to heal after cuts MISCULOSKELETAL YES NO Arthritis Back Pain Difficulty in walking Joint pain Joint stiffness or swelling Multiple sclerosis Muscle pain or cramps Muscular dystrophy Weakness of muscles or joints NEUROLOGICAL YES NO Convulsions or seizures Frequent/recurring headaches Head injury Light-headed or dizzy Migraines Numbness or tingling sensation Paralysis Sleep apnea PSYCHIATRIC YES NO Anxiety Depression Memory loss or confusion Nervousness Suicidal RESPIRATORY YES NO Asthma or wheezing Bronchitis Chronic or frequent cough Emphysema Shortness of breath Spitting up blood Tuberculosis VASCULAR YES NO Discoloration of extremities Leg Pain Leg swelling Varicose veins
New-patient-packet-2016.docx