Musculoskeletal: Arthritis Yes No □ □ Back Problems Yes No □ □ History of Gout Yes No □ □ Joint Stiffness Yes No □ □ Leg Cramps Yes No □ □ Painful Joints Yes No □ □ Swollen Joints Yes No □ □ Skin: Acne Yes No □ □ Blistering of Skin Yes No □ □ Discoloration Yes No □ □ Eczema Yes No □ □ Excessive Sun Exposure Yes No □ □ Keloid Formation Yes No □ □ Neurologic: Balance Difficulty Yes No □ □ Difficulty Speaking Yes No □ □ Dizziness Yes No □ □ Fainting Yes No □ □ Gait Abnormality Yes No □ □ Irritability Yes No □ □ Stroke Yes No □ □ Psychiatric: Auditory/Visual Hallucinations Yes No □ □ Delusions Yes No □ □ Mental or Physical Abuse Yes No □ □ Nervous Breakdown Yes No □ □ Psychiatric Condition Yes No □ □ Suicidal Thoughts Yes No □ □
Musculoskeletal: Arthritis □ Yes □ No Back Problems □ Yes □ No History of Gout □ Yes □ No Joint Stiffness □ Yes □ No Leg Cramps □ Yes □ No Painful Joints □ Yes □ No Swollen Joints □ Yes □ No Skin: Acne □ Yes □ No Blistering of Skin □ Yes □ No Discoloration □ Yes □ No Eczema □ Yes □ No Excessive Sun Exposure □ Yes □ No Keloid Formation □ Yes □ No Neurologic: Balance Difficulty □ Yes □ No Difficulty Speaking □ Yes □ No Dizziness □ Yes □ No Fainting □ Yes □ No Gait Abnormality □ Yes □ No Irritability □ Yes □ No Stroke □ Yes □ No Psychiatric: Auditory/Visual Hallucinations □ Yes □ No Delusions □ Yes □ No Mental or Physical Abuse □ Yes □ No Nervous Breakdown □ Yes □ No Psychiatric Condition □ Yes □ No Suicidal Thoughts □ Yes □ No
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