Health History Questionnaire (Page 3 of 4) in pdf

Health History Questionnaire Page 3

Please check if you have had (in the last three months):

GENERAL

! Poor appetite

! Poor sleeping

! Fatigue

! Fevers

! Chills

! Night Sweats

! Sweat easily

! Tremors

! Cravings

! Localized weakness

! Poor balance

! Change in appetite

! Bleed or Bruise easily

! Weight loss

! Weight gain

! Peculiar tastes or smells

! Sudden energy drop (What time of day)?

! Strong thirst (cold or hot drinks)

SKIN & HAIR

! Rashes

! Ulcerations

! Hives

! Itching

! Eczema

! Pimples

! Dandruff

! Hair loss

! Recent moles

! Change in skin or hair textures

Any other skin or hair problems?

HEAD, EYES, EARS, NOSE, & THROAT

! Dizziness

! Concussions

! Migraines

! Glasses

! Eye strain

! Eye pain

! Poor vision

! Night blindness

! Color blindness

! Cataracts

! Blurred vision

! Earaches

! Ringing in ears

! Poor Hearing

! Spots in front of eyes

! Sinus problems

! Nose bleeds

! Recurring soar throat

! Grinding teeth

! Facial pain

! Sore on lips or tongue

! Teeth problems

! Jaw clicks

Headaches (where and when)?

Any other head or neck problems?

CARDIVASCULAR

! High blood pressure

! Low blood pressure

! Chest pain

! Irregular heartbeat

! Dizziness

! Fainting

! Cold hands or feet

! Swelling of hands

! Swelling of feet

! Blood clots

! Phlebitis

! Difficulty in breathing

Any other heart or blood vessel problems?

RESPIRATORY

! Cough

! Coughing blood

! Asthma

! Bronchitis

! Pneumonia

! Pain with deep breathe

! Difficulty breathing while lying down

! Production of phlegm (what color?)

Any other lung problems?

Health History Questionnaire Page 3

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