Patient Questionnaire Form Page 2
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1
2SYSTEM REVIEW:
CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING SYMPTOMS OR FINDINGS TO AN UNUSUAL
OR SIGNIFICANT DEGREE:
HEADACHE ...........................
TROUBLE
HEART TROUBLE .................
DIABETES .............................
SWALLOWING ..................
FAINTING ..............................
HEART MURMUR .................
HYPOGLYCEMIA ..................
LOSS OF APPETITE .............
DIZZINESS ............................
RHEUMATIC FEVER .............
THYROID TROUBLE .............
INDIGESTION .......................
SEIZURE ...............................
PALPITATION ........................
G0ITER ..................................
HEART BURN .......................
EAR TROUBLE .....................
IRREGULAR HEART BEAT...
HOT FLASHES ......................
NERVOUS STOMACH ..........
SINUS TROUBLE ..................
TIRE EASILY .........................
FLUID RETENTION ..............
ULCERS ................................
STUFFY NOSE .....................
ANGINA .................................
WEAKNESS ..........................
VOMITING BLOOD ...............
NOSE BLEEDS .....................
ENLARGED HEART ..............
NERVOUS .............................
PASSING BLOOD .................
ALLERGY ..............................
HIGH BLOOD
IRRITABLE ............................
ABDOMINAL PAIN ................
PRESSURE .......................
HOARSENESS ......................
DEPRESSED ........................
COLITIS .................................
ANKLE SWELLING ...............
TIRED ....................................
DIARRHEA ............................
COUGH .................................
TROUBLE SLEEPING ...........
CONSTIPATION ....................
ARTHRITIS ............................
WHEEZING ...........................
HEMORRHOIDS ...................
BACK PAIN ............................
PLEURISY .............................
KIDNEY TROUBLE ...............
CHANGE IN BOWEL
BURSITIS ..............................
PNEUMONIA .........................
URINE INFECTION ...............
HABITS ..............................
MUSCLE CRAMPS ................
TUBERCULOSIS ...................
DIFFICULTY URINATING ......
GALL BLADDER
NUMBNESS ..........................
TROUBLE ..........................
SHORTNESS OF BREATH ...
PROSTATE TROUBLE ..........
VARICOSE VEINS .................
YELLOW JAUNDICE
NIGHT SWEATS ....................
SUGAR IN URINE .................
(HEPATITIS) .......................
PHLEBITIS ............................
CHEST PAIN .........................
BLOOD IN URINE .................
LIVER DISEASE ....................
INFERTILITY
COUGHED UP BLOOD .........
INJFERTILITY .......................
ABNORMAL ELECTRO-
ASTHMA ................................
IMPOTENCE .........................
CARDIOGRAM (EKG) .......
ANEMIA .................................
DECREASED LIBIDO ...........
ABNORMAL X-RAY ...............
BLOOD DISORDER ..............
OTHER ...................................
HIGH BLOOD SUGAR ..........
SKIN TROUBLE ....................
LOW BLOOD SUGAR ...........
TUMOR OR SWELLING ........
ACTIVITY (CHECK ONE OR MORE BOXES):
III OCCASIONAL VIGOROUS ACTIVITY WITH
I
SEDENTARY LIFE WITH LITTLE EXERCISE ........................
WORK OR RECREATION .....................................................
II MILD EXERCISE WITH JOB, HOUSE OR RECREATION
IV REGULAR VIGOROUS EXERCISE PROGRAM
(CLIMB STAIRS, WALK OVER 3 BLOCKS, GOLF,
BOWL, ETC.) ..........................................................................
OR HARD WORK ....................................................................
DATE LAST
ANY MENSTRUAL PROBLEMS:
YES
NO
MENSTRUATED?__________
HEAVY PERIODS _________________
IRREGULAR PERIODS_______________
PERIOD EVERY _____ DAYS
INFREQUENT PERIODS ___________
PAINFUL PERIODS __________________
NUMBER OF
NUMBER OF
BIRTH CONTROL METHOD DATE OF LAST MAMMOGRAM:________
PREGNANCIES _______
MISCARRIAGES_______
(IF ANY)_______________
PAP SMEAR:______________
CHECK IF YOU
D&C
TOXEMIA
ABNORMAL PAP
HAVE HAD:
HYSTERECOMY
CESAREAN SECTION
DIFFICULT WITH PREGNANCY
DIFFICULTY WITH LABOR
DIFFICULTY WITH DELIVERY
______________________________________________
FORM FILLED OUT BY:
SIGNATURE
PROVIDER: __________________________________DATE: _______________
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