Constitutional Yes No Respiratory Yes No Yes No Weight loss Cough Easy Bruising Coughing Blood Fatigue Bleeding gums Fever Wheezing Enlarged glands Eyes Chills Musculoskeletal Glasses/Contact Gastrointest. Joint Pain/Swelling Eye Pain Heartburn/ Stiffness Reflux Double vision Nausea/Vomitting Muscle Pain Cataracts Constipation Back Pain Ear, Nose, Change in BMs Skin Throat Difficulty Diarrhea Rash/Sores hearing Ringing in the Jaundice Lesions ears Vertigo Abdominal Pain Itching/Burning Sinus trouble or Bloody Neurological Stools Genitourinary Nasal stuffiness Loss of Strength Frequent sore Burning/ Numbness throat Frequency Cardiovasc Nighttime Headaches Frequency Murmur Blood in Urine Tremors Pain Erectile Memory Loss Dysfunction Palpitations Abnormal Addictive Behaviors Discharge Bladder Leakage Dizziness Gambling Fainting Spells Allergic Shopping/Spending Shortness of Hives/Eczema Internet Breath Difficulty lying Hay Fever Pornography flat Swelling ankles Psychiatric Sex Endocrine Anxiety Gaming Loss of hair Depression Food Heat/cold Mood swings Reviewed by: Date: Intolerant
Constitutional Yes No Respiratory Yes No Yes No Weight loss Cough Easy Bruising Fatigue Coughing Blood Bleeding gums Fever Wheezing Enlarged glands Eyes Chills Musculoskeletal Glasses/Contact Gastrointest. Joint Pain/Swelling Eye Pain Heartburn/ Reflux Stiffness Double vision Nausea/Vomitting Muscle Pain Cataracts Constipation Back Pain Ear, Nose, Throat Change in BMs Skin Difficulty hearing Diarrhea Rash/Sores Ringing in the ears Jaundice Lesions Vertigo Abdominal Pain Itching/Burning Sinus trouble or Bloody Stools Neurological Nasal stuffiness Genitourinary Loss of Strength Frequent sore throat Burning/ Frequency Numbness Cardiovasc Nighttime Frequency Headaches Murmur Blood in Urine Tremors Pain Erectile Dysfunction Memory Loss Palpitations Abnormal Discharge Addictive Behaviors Dizziness Bladder Leakage Gambling Fainting Spells Allergic Shopping/Spending Shortness of Breath Hives/Eczema Internet Difficulty lying flat Hay Fever Pornography Swelling ankles Psychiatric Sex Endocrine Anxiety Gaming Loss of hair Depression Food Heat/cold Intolerant Mood swings Reviewed by: Date:
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