Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Home Number

(###)

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Cell Number

(###)

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CURRENT AND PAST HEALTH CONDITIONS/SYMPTOMS/TRAUMAS

GENERAL

Insomnia

Dreams/nightmares

Fatigue

Poor Memory

Strongly like cold drinks

Strongly like hot drinks

Recent weight loss/gain

Cold hands & feet

Chills

Fever

Bad Breath

Other

Head & Neck

Headaches

Migraines

Stiff neck

Dizziness

Fainting

Swollen glands

Other

Ears

Ringing

Hearing loss

Hearing aids

Infections

Earache

Vertigo

Other

Eyes

Glasses/contact lenses

Blurred vision

Poor night vision

Spots or floaters

Eye Inflammation

Double vision

Glaucoma

Cataracts

"Lazy' eye

Other

Nose, Throat & Mouth

Sinus Infection

Hay fever/allergies

Frequent sore throat

Difficulty swallowing

Mouth & tongue ulcers

Frequent colds

Nosebleed

Dry nose

Nasal congestion

Loss of voice

Thirst

Excessive phlegm

TMJ

Facial pain

Gum problems

Dry mouth

Other

Skin

Hives

Rashes

Eczema/psoriasis

Night Sweating

Dry Skin

Easily bruised

Changes in moles, lumps

Itching

Other

Respiratory

Difficulty breathing

Difficulty breathing when reclining

Wheezing

Asthma

Chronic Cough

Wet Cough

Dry Cough

Coughing up phlegm

Coughing up blood

Shortness of breath

Tight chest

Pneumonia

Other

Cardiovascular

High blood pressure

Low blood pressure

Chest pain or tightness

Palpitation

Rapid heart beat

Poor circulation

Swollen ankles

Phlebitis

Anemia

History of heart disease

Heart murmur

Night sweats

Tendency to be cold

Tendency to be warm

Other

Gastrointestinal

Nausea

Indigestion

Stomach Pain

Diarrhea

Constipation

Poor appetite

Excessive hunger

Vomiting

Gas

Hiccups

Acid regurgitation

Bloating

Laxative use

Bloody stool

Other

Musculoskeletal

Joint pain/swelling

Sore muscles

Weak muscles

Difficulty walking

Pain

Limited range of motion

Other

Neurological

Seizures

Tremors

Numbness or tingling

Pain

Paralysis

Poor coordination

Other

Mental/Emotional

Depression

Mood swings

Irritability

Difficulty relaxing

Loneliness

Sensitive

Shyness

Frequent crying

Worries frequently

Compulsive behaviors

Difficulty focusing

Hopeless outlook

Suicidal thoughts

Lose temper

Frustration

Other

Urinary

Pain during urination

Frequent urination

Urgent urination

Blood in urine

Incontinence

Incomplete urination

Bedwetting

Wake to urinate

History of UTI

Kidney

Other

Male Genital

Impotence

Premature ejaculation

Nocturnal emission

Pain/itching of genitalia

Lumps in testicles

Increased libido

Decreased libido

Breast checked

Other

Gynecology (Women Only)

Currently pregnant

# of Pregnancies

# of Live births

# of Miscarriages

# of Abortions

Menopause

Irregular periods

Menstrual cramps

Excessive blood flow

Menstrual blood flow

Breast tenderness

Abnormal pap smear

Vaginal infections

Vaginal pain/itching

Uterine fibroids

Endometriosis

Breast lumps, cysts

Increased libido

Decreased libido

Other

Infection Screening

HIV risks: self or partner

TB: self or household

Hepatitis risk: self or partner

History of sexually transmitted disease: self or partner

Other

Date

MM

DD

YYYY