Patient history

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.

CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:
PneumoniaRheumatismPolioTuberculosisWhooping CoughPleurisySmall PoxDiabetesCancerHeart DiseaseThyroidGoutArthritisEpilepsyMental DisorderEczemaAnemiaOther

HEALTH HABITS:
Atcohol (>2 drinks per week)Cigarettes

Do You Exercise Regularly?
YesNo

How would you rate your nutrition?
ExcellentFairPoor

Have you been tested HIV positive?
YesNo

CHECK ANY OF THE FOLLOWING YOU HAVE HAD:

MUSCULO-SKELETAL CODE
Low Back PainPain between ShouldersNeck PainShoulder PainArm PainMid back Painjoint Pain/StiffnessWalking ProblemsDifficult Chewing/Clicking JawGeneral StiffnessMuscle Twitching/SpasmsSwollen jointsPain Legs/FeetSciatica
NERVOUS SYSTEM CODE
NervousLoss of BalanceNumbnessDizzinessForgetfulness (Memory/Concentration)DepressionConvulsionsNumber/Tingling ExtremitiesStressFatigue/Low EnergyAllergies/Hay feverLoss of Sleep / Sleep troubleFeverHeadachesInner Tension/StressIrritability
GASTRO-INTESTINAL CODE
Poor/Excessive ApetiteExcessive ThirstFrequent NauseaVommiting / DiarrheaConstipationHemorrhoidsLiver ProblemGall Bladder ProblemsWeight TroubleAbdominal CrampsIndigestionGas/Bloating after MealsHeartburnBlack/Bloody StoolColitisUlcers

GENITO-URINARY CODE
Bladder TroublePainful/Excessive UrinationDiscolored UrineKidney Trouble
CARDIO- VASCULAR CODE
Chest PainShortness of BreathHigh Blood PressureHigh CholesterolIrregular HeartbeatHeart ProblemsLung Problems/CongestionVaricose VeinsAnkle SwellingStrokeAsthma
EENT CODE
Vision ProblemDental ProblemsSore ThroatEar AcheHearing DifficultSinus TroubleLoss of SmellLoss of TasteRinging in ears
MALES ONLY CODE
ProstateSexual Dysfunction

FAMILY HISTORY

The following members have the same or similar problem as I do:
MotherFatherBrotherSisterSpouseChild
FEMALES ONLY
Menstrual IrregularityMenstrual CrampsVaginal Pain/InfectionBreast Pain/LumpsOther

When was your last period?

Are you pregnant?
YesNoNot Sure

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