Patient Symptom Chart Template
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1PATIENT SYMPTOM CHART
Mark the areas on the person that represent your symptoms.
Include all affected areas. Please use the appropriate symbols.
•••••
/////=Stabbing
=Burning ++++= Aching
VVVV=Numbness >>>>=Throbbing
XXXX=Pain
Please circle the number that best describes severity of your complaint. Severity
Least 0------------------------10 Most
Headache:
0 1 2 3 4 5 6 7 8 9 10
Neck:
0 1 2 3 4 5 6 7 8 9 10
Low Back:
0 1 2 3 4 5 6 7 8 9 10
Other A:
0 1 2 3 4 5 6 7 8 9 10
Other B:
0 1 2 3 4 5 6 7 8 9 10
Other C:
0 1 2 3 4 5 6 7 8 9 10
PATIENT HEALTH REVIEW
GENERAL
MUSCLE AND JOINT
RESPIRATORY
Cancer
Joint Disorder_____________________
COPD____
Type____________________________
Spinal Disorder____________________
Emphysema____
________________________________
Neck____________________________
Wheezing____
Diabetes: Type I II How Long_______
Thoracic_________________________
Chronic Phlegm____
Heart Disease____________________
Lumbar__________________________
Chronic Cough____
Stroke____
Arms/ Hands______________________
Productive Cough: Phlegm / Blood
Transient Ischemic Attack (TIA)____
Legs/ Feet________________________
Frequent Colds____
Headaches____
Pelvis____________________________
Asthma: Regular / Allergies / Exercise
Migraines____
OsteoArthritis______________________
Insomnia____
Rheumatoid Arthritis_________________
REPRODUCTIVE
Depression____
Inflammatory Condition_______________
Discharge___________________
Fatigue____
Herniated Disc_____________________
Itching/Pain__________________
Psychiatric Counsel____
Pinched Nerve_____________________
Lumps______________________
Psychological Therapy____
Scoliosis__________________________
Infections____________________
Aversion to Heat____
Tendonitis________________________
Pap Smear___________________
Aversion to Cold____
Menstrual Periods_____________
Thirst____
Menarche____________________
Overall Feeling__________________
Incontinence__
SKIN
GASTROINTESTINAL
NEUROLOGICAL
INFECTIOUS CONDITIONS
Hives____
Nausea
Pain____
Oral Ulcers/Canker Sores
Rashes____
Indigestion
Numbness____
Genital Herpes
Eczema ____
Stomach Pain
Tingling____
Rashes_____________________
Night sweating ____
Diarrhea
Burning____
HIV________________________
Excess sweating ____
Constipation
Tremors____
Blood Transfusions <1985
Bruise easily____
Bloody/black stools
Seizures____
STD_____________________
Changes in moles or lumps____
Gallbladder disorder
Headaches____
Chicken Pox____
Other_____________________
Change in Weight
Paralysis____
Measles__ Mumps __ Rubella__
__________________________
Food Cravings___________
Impairment____
Tuberculosis
__________________________
Other_________________
Other_________________
Other___________________
____
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