GENERAL SYMPTOMS Check (I) symptoms you currently have or have had in the past year.
GD8tAL
GASTROItfnST1NAL
o Numbness
o Appetite Poor
o Bloating
o Bowel Cbanges
o Constipation
o Diarrhea
o Excessive bnnger
o Excessive thirst
o Gas
o Hemorrboids
o Indigestion
o Nauses
o Rectal bleeding
o Stomacb pain
o Vomiting
o Sweats
D Vomiting
o Bruise easily
o Chills
o Dental Problems
o Depression
o Difficulty sleeping
o Dizziness
o Fainting
o Fever
o Forgetfulness
o Headacbe
o Loss of Sleep
o Loss ofWeigbt
o Nervousness
o TIredness
o Weigbt gain
o Lack
urine
urination
of bladder control
o Painful
urination
MEN only
o Breast Lump
o Erection difficulties
o Lump in testicles
o Penis discharge
o Sore on penis
o Bleeding gums
o Blurred vision
o Crossed eyes
o Difficulty swallowing
o Double vision
o Earacbe
o Ear discbarge
o Hay fever
o Hoarseness
o Loss of bearing
o Nosebleeds
D Persistent
D Otber
WOIII!N ONLY
o Abnormal
blood
pap smear
D Bleeding between periods
o Breast lump
o Extreme menstrual
o Hot f1asbes
o Nipple disc barge
o Painful intercourse
o Vaginal discbarge
o Otber
cougb
o Ringing in ears
o Sinus problems
o Vision-f1asbes
o Vision-balos
CARDIOVASCULAR
GI!NITO-URINARY
o Blood in
o Frequent
EYe,I!AR,NOSE,THROAT
pain
o Chest pain
o Higb blood pressure
o Irregular beart beat
o Low blood pressure
o Poor circulation
o Bruise easily
o Hives
o Itcbing
o Cbange in moles
Have you bad a mammogram?
D Rapid heart beat
DRash
Are you pregnant?
o Swelling
o Scars
o Sore tbat
Date of last menstrual
SKIN
of ankles
D Varicose veins
period
Date of last Pap Smear
Number
NO
YES
of cbildren
won't beal
NECK, BACK, EXTREMITIES Check (vi) symptoms you currently have or have had in the past year.
o Pain in neck
o Neck stiffness
o Neck
ARMS & HANDS
o Pain
weakness
o Pinched
nerve in neck
D Neck feels out of place
o Muscle spasms in neck
o Grinding/popping sounds
in neck
SHOULDeRS
DR
o Pain
pain
stiffness
between sboulder
Left
OL
OL
level
MlD-8ACK
o Mid-back
o Mid-back
RIght
DR
D Pain in shoulder joint
o Pain across sboulders
o Can't raise arm
o Above sboulder
o Over bead
o Tension in sboulders
o Pinched nerve in shoulder
o Low back feels out of place
o Muscle spasms in low back
o Pain from front to back
o Muscle spasms in mid-back
NRK
blades
DR
OL
in upper arm
o Pain in elbow
o Pain in forearm
o Pain in hand
o Pain in fingers
o Pins & needles in arm
o Pins & needles in fingers
o Numbness in arm
o Numbness in fingers
o Weakness of arm
o Weakness of band
o Hands cold
HIps' LEGS & FEET RIght
L.rt
RIght
DR
OL
DR
OL
DR
OL
DR
OL
DR
OL
DR
OL
o Pain
in buttocks
DR
OL
o Pain
o Pain
in bip joint
DR
OL
down leg
DR
OL
o Pain
o Pain
o Pain
in knee
DR
OL
in anlde
DR
OL
in foot
DR
OL
o Weakness ofleg
o Weakness of knee
o Leg Cramps
DR
OL
OTHERSYMPTOMS
DR
OL
DR
OL
DR
OL
DR
OL
Left
DR
OL
DR
DL
DR
OL
DR
OL
LOW BACK
o Low back pain
o Low back stiffness
o Low back weakness
o Pincbed nerve in low
I certifY tbat the above information is correct to tbe best of my knowledge.
errors or omissions that I may have made in the completions of tbis form.
back
I will not bold my doctor or any members
of his/her staff responsible
Patient Signature
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O8te __
Reviewed by Doctor
_
Date
-'-
for any
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