Health-form Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care. GenderMaleFemaleTransgender Check Any Of the following Disease's have Had: Pneumonia Small Pox Arthritis Rheumatic Fever Diabetes Epilepsy Polio Cancer Mental Disorder Tuberculosis Heart Disease Eczema Whooping Cough Thyroid Anemia Pleurisy Gout Other Have you been tested HIV positive? YesNo Health Habits: Alcohol (>2 drinks per week) Cigarettes Do You Exercise Regularly? YesNo How would you rate your nutrition? ExcellentFairPoor Check Any Of the following Disease's have Had: Musculo-Skeletal Code Low Back Pain Pain between Shoulders Neck PainShoulder Pain Arm PainMid back Pain joint Pain/Stiffness Walking Problems Difficult Chewing/Clicking Jaw General Stiffness Muscle Twitching/Spasms Swollen joints Pain Legs/Feet Sciatica Nervous System Code NervousLoss of Balance Numbness Dizziness Forgetfulness (Memory/Concentration) Depression Convulsions Numb/Tingling Extremities Stress General Code Fatigue/Low Energy Allergies/Hay Fever Loss of Sleep/Trouble Sleeping Fever Headaches inner Tension/Stress Irritability Gastro-Intestinal Code Poor/Excessive Apetite Excessive Thirst Frequent Nausea Vomiting Diarrhea Constipation Hemorrhoids Liver Problems Gall Bladder Problems Weight Trouble Abdominal Cramps Indigestion Gas/Bloating after Meals Heartburn Black/Bloody Stool Colitis Ulcers Genito-Urinary Code Bladder Trouble Painful/Excessive Urination Discolored Urine Kidney Trouble Cardio-Vascular Code Chest Pain Shortness of Breath High Blood Pressure High Cholesterol Irregular Heartbeat Heart Problems Lung Problems/Congestion Varicose Veins Ankle Swelling Stroke Asthma Eent Code Vision Problem Dental Problems Sore Throat Ear Ache Hearing Difficult Sinus Trouble Loss of Smell Loss of Taste Ringing in ears Males Only Code Prostate Sexual Dysfunction Please outline on the diagram the area of your discomfort. Family History The following members have the same or similar problem as I do; Mother Father Brother Sister Spouse Child Females Only Menstrual Irregularity Menstrual Cramps Vaginal Pain/Infection Breast Pain/Lumps Other When was your last period? Are you pregnant? YesNoNot Sure