Confidential Health History Form Page 4
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5Body Systems Review
Please mark all of the conditions below that you have now (X) or had in the past (P)
ENDOCRINE
___
Concussion/trauma to head
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Ear ringing
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Hypo- or hyper- thyroidism
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Other:_________________
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Itching
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Diabetes
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Decreased Hearing
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Hypoglycemia
FEMALE REPRODUCTIVE
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Other:_________________
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Other ___________________
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Frequent urinary tract
infections
NOSE, THROAT & MOUTH
GASTRO-INTESTINAL
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Pelvic Inflammatory Disease
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Frequent sinus infections
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Nausea or vomiting
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Endometriosis
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Seasonal allergies
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Diarrhea
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Ovarian Cyst
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Grinding teeth
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Constipation
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Uterine Fibroid
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Goiter
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Irritable Bowel Syndrome
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Abnormal Pap smear
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Other:_________________
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Indigestion
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Irregular Periods
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Rectal Pain/hemorrhoids
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Painful menstrual periods
NEUROLOGICAL
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Gallstones
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Pre-menstrual symptoms
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Seizures
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Heart Burn/Acid Reflux
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Menopause symptoms
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Tremors
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Ulcer
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Breast lumps
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Numbness/tingling in limbs
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Other ____________________
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Infertility
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Pain ___________________
___
Low libido
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Paralysis
CARDIOVASCULAR
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Other ___________________
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Migraine
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High or low blood pressure
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Concussion
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Blood clots
MALE REPRODUCTIVE
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Other:_________________
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Heart disease
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Impotence
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Anemia
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Erectile difficulty
EYES
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Varicose veins
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Premature ejaculation
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Blurred vision
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Cold Hands/Feet
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Low libido
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Eye pain
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Swelling of Hands/Feet
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Prostatitis
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Cataracts
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Heart Murmur
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Other:_________________
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Eyeglasses/contact lenses
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Other ____________________
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Other:_________________
SKIN
RESPIRATORY
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Warts
MUSCULO-SKELETAL
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Asthma
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Rashes
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Osteoporosis
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Bronchitis
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Psoriasis
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Joint Pain
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Chronic Obstructive
___
Eczema
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Fibromyalgia
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Pulmonary Disease
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Other ____________________
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Back or Neck Pain
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Pneumonia
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Foot Pain
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Chest Congestion
GENITO-URINARY
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Hand Pain
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Frequently catching colds
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Kidney stones
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Other:_________________
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Other ____________________
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Painful urination
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Frequent urination
IMMUNE/LYMPHATIC
HEAD AND NECK
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Urinary Incontinence
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Chronic Fatigue Syndrome
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Dizziness
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Other ___________________
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Rheumatoid Arthritis
___
Neck Stiffness
___
Aids/HIV
___
Headaches
___
Cancer
EARS
___
Jaw tightness/Pain
___
Other:_________________
___
Recurring ear infections
The Barefoot Dragonfly•11673 Jollyville Rd, Suite 201 • Austin, TX • 78759 • 512-666-9374 •
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