Patient History Information Form Page 4

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Integumentary
Changes to Existing Lesions
Rash
New Skin Lesions
Itching
or Moles
Skin Dryness
Acne
Hair Growth Change
Neurologic
Muscular Weakness
Seizures
Tingling or Numbness
Loss of Balance
Difficulty Concentrating
Memory Difficulties
Musculoskeletal
Joint Pain
Joint Swelling
Back Pain/ Injury
Muscle Pain
Limitation of Motion
Muscular Weakness
Endocrine
Excessive Urination
Excessive Thirst
Psychiatric
Thoughts of Hurting Yourself
Depression
Anxiety
Difficulty Sleeping
or Others
Hematology-Lymphatic
Lymph Node Enlargement or Tenderness
Easy Bruising
Allergic-Immunologic
Hayfever/ Seasonal Allergies
Hives
Frequent Illness

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