Body Pain Location Chart With Symptoms Questionnaire (Page 2 of 2) in pdf

Health and Medical History

-Circle all the present conditions, and underline the past conditions. List

approximate date condition began.

Acid Reflux

Constipation

Headache

Migraines

Low Blood Pressure

AIDS/HIV

Depression

Heart Disease

Memory Loss

High Cholesterol

Allergies

Diabetes

Hepatitis

Miscarriage

Psychiatric care

Anemia

Diarrhea

Herniated Disc

Mononucleosis

Rheumatoid Arthritis

Anorexia

Difficulty Sleeping

Herpes

Multiple Sclerosis

Stroke

Appendicitis

Dizziness

High Blood Pressure

Muscle Weakness

Seizures

Asthma

Emphysema

Insomnia

Mumps

Shortness of Breath

Bloating

Epilepsy

Irritability

Osteoporosis

Nausea

Bronchitis

Fainting

Kidney Disease

Osteopenia

Vertigo

Bulimia

Fatigue

Liver Disease

Pacemaker

Nervousness/Anxiety

Cancer

Fever

Light Sensitivity

Indigestion

Suicide Attempt

Cataracts

Fractures

Loss of Smell

Pneumonia

Scoliosis

Parkinson’s

Chicken Pox

Glaucoma

Loss of Libido

Thyroid Disorder

Cold Sweats

Goiter

Low Energy

Polio

Tonsillitis

Cold Feet or Hands

Gonorrhea

Measles

Prostate Disorder

Tuberculosis

TMJ Problems

Ulcers

Whooping Cough

Vaginal Infection

Prosthesis

Other_____________________________________________

Women only: Are you pregnant? No

Yes

If Pregnant: Date of Last Menstrual Period: _______________

Number of weeks? ___________________

Nursing?

Yes

Are you taking birth control pills? No

Yes

List Family history of illnesses known:

Mother:

Father:

Grandparents:

Siblings:

Aunties/Uncles:

List any surgeries or procedures which you have had:

________________________________________________Date_____/_____/______

List any allergies you have:____________________________________________________________________________

List any medications or nutritional supplements you are currently taking:_______________________________________

__________________________________________________________________________________________________

Patient Name:_____________________________________Date:_____/_____/_______Patient I.D.______________

Page 4 of 4

Body Pain Location Chart With Symptoms Questionnaire Page 2

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