Emory Healthcare Initial History Form Page 4

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Are you experiencing significant problems or do you have concerns with any of the following?
(Room for more comments is on next page.)
No
Yes
General
Comments
No
Yes
EENT
Comments
Weight loss
Blurred or bad vision
Weight gain
Spots before eyes
Fever or chills
Pain in eyes
Night sweats
Hoarseness
Problems with wound healing
Thrush
Increasing weakness, fatigue
Mouth sores
Dizziness
Difficulty hearing
Intolerance to heat or cold
Frequent nose bleeds
Poor appetite
Frequent sinus problems
No
Yes
Respiratory
Comments
No
Yes
Cardiovascular
Comments
Cough
Chest pain/discomfort
Wheezing/Asthma
Need to sleep head up
Sputum production
Irregular heartbeat
Shortness of breath
Fainting spell
Hx of exposure to tuberculosis
Swelling of feet/legs
Prior TB skin test (PPD)
High blood pressure
Hx of positive PPD
High cholesterol
Rheumatic heart disease
Heart murmur
No
Yes
Gastrointestinal
Comments
No
Yes
Genitourinary
Comments
Nausea/vomiting
Frequent urination
Vomiting blood
Painful urination
Blood in stools
Difficulty holding urine
Black/tarry stools
Decreased stream
Difficulty swallowing
Blood in urine
Indigestion/Heartburn
Penile/vaginal discharge
Abdominal pain
Frequent vaginal yeast
Diarrhea
Sores/lesions genitals
Constipation
Pain/masses breasts
Hemorrhoids
Nipple discharge
History of hepatitis
No
Yes
Musculoskeletal/Skin
Comments
No
Yes
Endocrine
Comments
Joint pain/swelling
Low thyroid (Hypo-)
Body ache/muscle cramps
High thyroid (Hyper-)
Morning stiffness
Diabetes
Itching
Excessive thirst
Rash
Change in breast size
Skin problems
Change in body hair
Easy bleeding
Nail problems
Decreased interest in sex
Problems with erection ♂
No
Yes
Neurologic
Comments
No
Yes
Psychiatric
Comments
Seizures
Depression
Headache
Anxiety
Tingling/numbness
Often feeling sad
Weakness on one side
Spontaneous crying
Vertigo/balance problems
Less interest in usual
activities
Sleep disturbances
Feelings of decreased self
worth
Hallucinations
Previous
psychiatrist/therapist?
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