Persistent Now the past In  Other: Now the past In  Gastrointestinal (Digestion) None  Ulcers Now the past In  Hepatitis / Problems Now the past In  Gall Bladder Disease Now the past In  Heartburn/GERD Now the past In  Chronic Constipation Now the past In  Diarrhea Now the past In  Persistent Nausea Now the past In  Vomiting  Blood in Stool Now the past In  Other: Now the past In  Urologic (Kidneys & Bladder) None  Frequent Urinary Infection Now the past In  Kidney Infection Now the past In  Kidney Disease Now the past In  Bladder Problems Incontinence (leaking) Now the past In Urinary Frequency Now the  In past Now Urinary Urgency  In the past Blood in Urine  Now the past In  Other: Now the past In  Musculoskeletal(Muscles& None  Osteoporosis Now the past Osteopenia  In  Arthritis: Type Now the past In  Fibromyalgia Now the past In  Fractures Now the past In  Other: Now the past In  Eyes, Ear, Nose, Throat None  -Type Glaucoma Now the past In  Hearing Problems Now the past In  Seasonal Allergies/Hay Fever Now the past In  Cataracts Now the past In  Other eye Now the past In  problems: Current dental issues? Yes No  Other: Now the past In  Endocrine (Glands) None  Diabetes Mellitus: Type I or II Now the past In  Thyroid Disease Now the past In  Other: Now the past In  Hematology Disorders) None  Anemia Now the past In  Clots / Pulmonary Embolism Now the past In  Other: Now the past In  Lupus/ SLE Now the past In  Cancer None 
Persistent Now In the past  Other: Now In the past  Gastrointestinal (Digestion) None  Ulcers Now In the past  Hepatitis / Problems Now In the past  Gall Bladder Disease Now In the past  Heartburn/GERD Now In the past  Chronic Constipation Now In the past  Diarrhea Now In the past  Persistent Nausea Vomiting  Now In the past  Blood in Stool Now In the past  Other: Now In the past  Urologic (Kidneys & Bladder) None  Frequent Urinary Infection Now In the past  Kidney Infection Now In the past  Kidney Disease Now In the past  Bladder Problems Incontinence (leaking) Urinary Frequency Urinary Urgency Now In the past  Now In the past  Now In the past  Blood in Urine Now In the past  Other: Now In the past  Musculoskeletal(Muscles& None  Osteoporosis Osteopenia  Now In the past  Arthritis: Type Now In the past  Fibromyalgia Now In the past  Fractures Now In the past  Other: Now In the past  Eyes, Ear, Nose, Throat None  Glaucoma -Type Now In the past  Hearing Problems Now In the past  Seasonal Allergies/Hay Fever Now In the past  Cataracts Now In the past  Other eye problems: Now In the past  Current dental issues? Yes No  Other: Now In the past  Endocrine (Glands) None  Diabetes Mellitus: Type I or II Now In the past  Thyroid Disease Now In the past  Other: Now In the past  Hematology Disorders) None  Anemia Now In the past  Clots / Pulmonary Embolism Now In the past  Other: Now In the past  Lupus/ SLE Now In the past  Cancer None 
clinic_patient_registration_packet_2018.docx