Patient Information And History Form Page 3
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4(Do you have any of the following symptoms, if yes, explain)
Constitutional:
Integument:
Fever
Y_____N_____
Skin rash
Y_____N_____
Chills
Y_____N_____
Itching
Y_____N_____
Headache
Y_____N_____
Moles
Y_____N_____
Weight Loss
Y_____N_____
Skin tumors Y_____N_____
Eyes:
Muscoloskeletal:
Blurred vision
Y_____N_____
Neck pain
Y_____N_____
Double vision
Y_____N_____
Back pain
Y_____N_____
Pain
Y_____N_____
Hip pain
Y_____N_____
Glaucoma
Y_____N_____
Shoulder pain Y_____N_____
Cataracts
Y_____N_____
Hand pain
Y_____N_____
Allergic/immunologic:
Ear/Nose/Throat:
Hay fever
Y_____N_____
Ear infection Y_____N_____
Food allergies
Y_____N_____
Sore throat
Y_____N_____
AIDS
Y_____N_____
Sinus infection
Y_____N_____
Neurological:
Respiratory:
Tremors Y_____N_____
Wheezing
Y_____N_____
Dizzy spells
Y_____N_____
Cough
Y_____N_____
Numbness
Y_____N_____
Asthma
Y_____N_____
Tingling Y_____N_____
Shortness of breath Y____N____
Seizures Y_____N_____
Weakness
Y_____N_____
Endocrine:
Hematological/Lymphatic
Excessive thirst Y_____N____
Swollen glands
Y_____N_____
Too hot
Y_____N_____
Blood clotting
Too coldY_____N_____
Problems
Y_____N_____
Fatigue
Y_____ N_____
Gastrointestinal:
Psychological:
Abdominal pain Y_____N_____
Depression
Y_____N_____
Nausea
Y_____N_____
Anxiety
Y_____N_____
Vomiting
Y_____N_____
Bipolar Disorder
Y_____N_____
Constipation
Y_____N_____
Attention Deficit
Y_____N_____
Diarrhea Y_____N_____
Can=t sleep
Y_____N_____
Cardiovascular
Chest pain
Y____N____
Palpitations
Y____N____
Varicose veins
Y____N____
Can=t sleep lying flat
Y____N____
Please initial here______
MALE ONLY
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Parent category: Medical