Sensitive to cold Diarrhea Extremities cold or clammy Constipation Hands/Feet go to sleep/numbness/tingling Changes in bowels High blood pressure Rectal bleeding Chest pain Tarry stools Pain between shoulders Rectal itching Dizziness upon standing Use laxatives Fainting spells Bloating High cholesterol Belch frequently High triglycerides Anal itching Wheezing Anal fissures Irregular heartbeat Bloody stools Palpitations Undigested food in stools Low exercise tolerance Frequent coughs KIDNEY/URINARY TRACT: Breathing heavily Burning Frequently sighing Frequent urination Shortness of breath Blood in urine Night sweats Night time urination Varicose veins/spider veins Problem passing urine Mitral valve prolapse Kidney pain Murmurs Kidney stones Skipped heartbeat Painful urination Heart enlargement Bladder infections Angina pain Kidney infections Bronchitis/Pneumonia Syphilis Emphysema Bedwetting Croup Have trichomonas Frequent colds Heavy/tight chest HISTORY (for women only) WOMEN’S Prior heart attack ? When___/___/_____ Fibrocystic breasts Phlebitis Lumps in breast Fibroid Tumors/Breast Spotting Heavy periods GASTROINTESTINAL Fibroid Tumors/Uterus Peptic/Duodenal Ulcer Poor appetite HISTORY (for women only) WOMEN’S Excessive appetite Painful periods Gallstones Change in period Gallbladder pain Breast soreness before period Nervous stomach Endometriosis Full feeling after small meal Non-period bleeding Indigestion Breast soreness during period Heartburn Vaginal dryness Acid Reflux Vaginal discharge Hiatal Hernia Partial/total hysterectomy Nausea Hot flashes Vomiting Mood swings Vomiting blood Concentration/Memory Problems Abdominal Pains/Cramps Breast cancer Gas Ovarian cysts
Sensitive to cold Extremities cold or clammy Hands/Feet go to sleep/numbness/tingling High blood pressure Chest pain Pain between shoulders Dizziness upon standing Fainting spells High cholesterol High triglycerides Wheezing Irregular heartbeat Palpitations Low exercise tolerance Frequent coughs Breathing heavily Frequently sighing Shortness of breath Night sweats Varicose veins/spider veins Mitral valve prolapse Murmurs Skipped heartbeat Heart enlargement Angina pain Bronchitis/Pneumonia Emphysema Croup Frequent colds Heavy/tight chest Prior heart attack ? When___/___/_____ Phlebitis GASTROINTESTINAL Peptic/Duodenal Ulcer Poor appetite Excessive appetite Gallstones Gallbladder pain Nervous stomach Full feeling after small meal Indigestion Heartburn Acid Reflux Hiatal Hernia Nausea Vomiting Vomiting blood Abdominal Pains/Cramps Gas Diarrhea Constipation Changes in bowels Rectal bleeding Tarry stools Rectal itching Use laxatives Bloating Belch frequently Anal itching Anal fissures Bloody stools Undigested food in stools KIDNEY/URINARY TRACT: Burning Frequent urination Blood in urine Night time urination Problem passing urine Kidney pain Kidney stones Painful urination Bladder infections Kidney infections Syphilis Bedwetting Have trichomonas WOMEN’S HISTORY (for women only) Fibrocystic breasts Lumps in breast Fibroid Tumors/Breast Spotting Heavy periods Fibroid Tumors/Uterus WOMEN’S HISTORY (for women only) Painful periods Change in period Breast soreness before period Endometriosis Non-period bleeding Breast soreness during period Vaginal dryness Vaginal discharge Partial/total hysterectomy Hot flashes Mood swings Concentration/Memory Problems Breast cancer Ovarian cysts
Health-History-Form-patient-1.docx