Symptoms of: Comments Further testing? Skin disorders Yes No Headaches, dizziness Yes No Respiratory disorders Yes No Irritation of eyes, nose or Yes No throat Numbness in hands or Yes No feet CNS Yes No Others Yes No Height _____cm Weight _____kg Bp ____/____ mmHg Yes No OTHER MEDICAL HISTORY, FAMILY MEDICAL HISTORY, CURRENT MEDICATION, COMMENTS, TESTS OR RECOMMENDATIONS (use separate sheet if necessary)
Symptoms of: Comments Further testing? Skin disorders Yes No Headaches, dizziness Yes No Respiratory disorders Yes No Irritation of eyes, nose or throat Yes No Numbness in hands or feet Yes No CNS Yes No Others Yes No Height _____cm Weight _____kg Bp ____/____ mmHg Yes No OTHER MEDICAL HISTORY, FAMILY MEDICAL HISTORY, CURRENT MEDICATION, COMMENTS, TESTS OR RECOMMENDATIONS (use separate sheet if necessary)
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