__Heat sensation in feet, chest __night sweats __ catch colds easily __shortness of breath __sweat easily __ general weakness __ feel worse after exercise __dizziness __ see floating black spots __palpitations __restlessness __anxiety __chest pain __ insomnia __mental confusion __cough __nasal discharge __nose bleeds __sinus congestion __dry mouth, throat, nose, or skin __allergies __chills alternating with fever __sneezing __headache __feel achy __stiff neck/shoulders __sore throat __difficult breathing __low appetite __loose stools __constipation __abdominal bloating or gas after eating __fatigue after eating __prolapsed organs (previously diagnosed) __bruise easily __general feeling of heaviness in body __mental heaviness, sluggishness or fogginess __swollen hands __burning sensation after eating __large appetite __bad breath __mouth (canker) sores __bleeding, swollen or painful gums __heartburn __belching __vomiting __swollen feet __chest congestion __nausea __diarrhea __diarrhea alternating with constipation __feel better after exercise __pain in ribs or side __ tight feeling in chest __bitter taste in mouth __blood shot eyes __anger easily __skin rashes __headache at top of head __hot flashes __dry eyes __numbness of hands and feet __muscle spasms, twitching, cramping __seizures __sore, cold or weak knees __low back pain __frequent urination __do you get up at to urinate? __lack of bladder control __memory problems __hair loss __ringing in ears Urine is: __clear __light yellow __dark yellow __reddish yellow __ cloudy __scanty _ has odor __ burning __painful __ difficult __urgent Libido (sex is: Low1 2 3 4 5 6 7 8 9 10 High Please list 1-3 health goals that you have for the next 6 months: For the next year? For those with the applicable anatomy
__Heat sensation in feet, chest __night sweats __ catch colds easily __shortness of breath __sweat easily __ general weakness __ feel worse after exercise __dizziness __ see floating black spots __palpitations __restlessness __anxiety __chest pain __ insomnia __mental confusion __cough __nasal discharge __nose bleeds __sinus congestion __dry mouth, throat, nose, or skin __allergies __chills alternating with fever __sneezing __headache __feel achy __stiff neck/shoulders __sore throat __difficult breathing __low appetite __loose stools __constipation __abdominal bloating or gas after eating __fatigue after eating __prolapsed organs (previously diagnosed) __bruise easily __general feeling of heaviness in body __mental heaviness, sluggishness or fogginess __swollen hands __burning sensation after eating __large appetite __bad breath __mouth (canker) sores __bleeding, swollen or painful gums __heartburn __belching __vomiting __swollen feet __chest congestion __nausea __diarrhea __diarrhea alternating with constipation __feel better after exercise __pain in ribs or side __ tight feeling in chest __bitter taste in mouth __blood shot eyes __anger easily __skin rashes __headache at top of head __hot flashes __dry eyes __numbness of hands and feet __muscle spasms, twitching, cramping __seizures __sore, cold or weak knees __low back pain __frequent urination __do you get up at to urinate? __lack of bladder control __memory problems __hair loss __ringing in ears Urine is: __clear __light yellow __dark yellow __reddish yellow __ cloudy __scanty _ has odor __ burning __painful __ difficult __urgent Libido (sex is: Low1 2 3 4 5 6 7 8 9 10 High Please list 1-3 health goals that you have for the next 6 months: For the next year? For those with the applicable anatomy
initial_patient_intake_forms.docx