Pregnant Convulsions Infertility Dizziness Decreased libido Fainting Spells Heavy bleeding Blackouts/Amnesia Joint pains Had prior shock therapy Headaches Frequently keyed up and jittery Weight gain Startled by sudden noises Loss of bladder control Anxiety/Feeling of panic Palpitations Go to pieces easily Forgetful Listless/groggy Withdrawn feeling/Feeling ‘lost’ Had nervous breakdown HISTORY (for men only) MEN’S Unable to concentrate/short attention span Have you had a PSA done? Vision changes Yes _____ No _____ PSA Level: Unable to reason 0 2 Considered a nervous person by others – 2 4 Tends to worry needlessly – 4 10 Unusual tension – >10 Prostate enlargement Prostate infection Change in libido EMOTIONAL (CONTINUED) Impotence Diminished/poor libido Frustration Infertility Emotional numbness Lumps in testicles Often break out in cold sweats Sore on penis Profuse sweating Genital pain Depressed Hernia Previously admitted for psychiatric care Prostate cancer Often awakened by frightening dreams Low sperm count Family member had nervous breakdown Difficulty obtaining erection Use tranquilizers Difficulty maintaining an erection Misunderstood by others Nocturia (urination at night) Irritable/ How many times at night? ____ Feeling of hostility/volatile or aggressive Fatigue Urgency/Hesitancy/Change in Urinary Stream Hyperactive Loss of bladder control Restless leg syndrome Considered clumsy Unable to coordinate muscles Have difficulty falling asleep JOINT/MUSCLES/TENDONS Have difficulty staying asleep Pain wakes you Daytime sleepiness Weakness in legs and arms Am a workaholic Balance problems Have had hallucinations Muscle cramping Have considered suicide Head injury Have overused alcohol Muscle stiffness in morning Family history of overused alcohol Damp weather bothers you Cry often Feel insecure Emotional: Have overused drugs
Pregnant Infertility Decreased libido Heavy bleeding Joint pains Headaches Weight gain Loss of bladder control Palpitations MEN’S HISTORY (for men only) Have you had a PSA done? Yes _____ No _____ PSA Level: 0 – 2 2 – 4 4 – 10 >10 Prostate enlargement Prostate infection Change in libido Impotence Diminished/poor libido Infertility Lumps in testicles Sore on penis Genital pain Hernia Prostate cancer Low sperm count Difficulty obtaining erection Difficulty maintaining an erection Nocturia (urination at night) How many times at night? ____ Urgency/Hesitancy/Change in Urinary Stream Loss of bladder control JOINT/MUSCLES/TENDONS Pain wakes you Weakness in legs and arms Balance problems Muscle cramping Head injury Muscle stiffness in morning Damp weather bothers you Emotional: Convulsions Dizziness Fainting Spells Blackouts/Amnesia Had prior shock therapy Frequently keyed up and jittery Startled by sudden noises Anxiety/Feeling of panic Go to pieces easily Forgetful Listless/groggy Withdrawn feeling/Feeling ‘lost’ Had nervous breakdown Unable to concentrate/short attention span Vision changes Unable to reason Considered a nervous person by others Tends to worry needlessly Unusual tension EMOTIONAL (CONTINUED) Frustration Emotional numbness Often break out in cold sweats Profuse sweating Depressed Previously admitted for psychiatric care Often awakened by frightening dreams Family member had nervous breakdown Use tranquilizers Misunderstood by others Irritable/ Feeling of hostility/volatile or aggressive Fatigue Hyperactive Restless leg syndrome Considered clumsy Unable to coordinate muscles Have difficulty falling asleep Have difficulty staying asleep Daytime sleepiness Am a workaholic Have had hallucinations Have considered suicide Have overused alcohol Family history of overused alcohol Cry often Feel insecure Have overused drugs
Health-History-Form-patient-1.docx