Patient Encounter Form Page 4
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4Patient’s Name
CIRCLE OR UNDERLINE SYMPTOMS BROUGHT ON BY YOUR PROBLEM(S)
GENERAL:
Nervousness, Dizziness, Fainting, Sinus Trouble, Frequent Colds, Fatigue, Other:
HEADACHE:
WHERE (Front, Back, Right, Left)? Day, Night, Aching Throbbing, Sharp, Dull, With Vomiting, Stuffy Nose,
Better With Sleep, Worse With Tension, Spots Before Eyes, Other:
CAUSE: Migraine, Food, Sinus, Tension, Drug, Other:
SKIN:
Rash, Hives, Eczema, Blisters, Itching, Swelling, Burning, Stinging, Redness, Perspiration, Dandruff,
Athlete’s Foot (Where?
), Worse after eating? YES / NO
EYES:
Tearing, Burning, Itching, Pain, Redness, Discharge, Puffiness, Infections, Blurring of Vision, Glaucoma,
Other:
NOSE:
Trouble Smelling, Stuffiness, Sniffles, Itching, Sneezing, Snoring, Polyps, Post-Nasal Drip, Bleeding, Broken
Nose, Previous Surgery, Other:
TONGUE
Swollen, Sore, Itching, Coated, Trouble Eating, Other:
MOUTH:
Itching of Roof, Repeated Tonsillitis, Tonsils Removed, Adenoids Removed, Morning Sore Throats, Bad
Breath, Swollen Lips, Trouble Swallowing, Mouth Breathing, Frequent Throat Clearing, Change in Voice,
Other:
MUCUS:
Thick, Thin, Clear, Yellow, Green, Brown, Bloody, Amount Per Day (Teaspoon, Tablespoon, ½ Cup?),
Source of Mucus (Nose, Lungs, Throat), Other:
CHEST:
Shortness of Breath, Wheeze Pain, tightness, Cough, Cough When Wheeze, Trouble Walking, Trouble
Working, Trouble Sleeping, Heart Trouble, High Blood Pressure, Emphysema, Bronchitis, Pneumonia,
tuberculosis, Cancer, Other:
STOMACH:
Vomiting, Gas, Cramps, Bleeding, Diarrhea, Mucus in Stool, Blood in Stool, Foul Smelling Stool, Soiling,
Worse after Eating, What Foods?
Other:
JOINTS:
Pain Stiffness, Swelling, Other:
MENSES:
FEMALE ONLY. Regular, Irregular, Discharge, Itch, Cramps, Infections, Last Period (Date:
),
Pain, Are You Pregnant? YES / NO, Taking Birth Control? YES / NO
MENOPAUSE:
FEMALE ONLY. Menopause Symptoms: Hot Flashes, Vaginal Dryness, Insomnia, Mood Changes,
Other:
KIDNEY:
Pain, Frequent Urination, Bladder Infection, Recurrent Infection, Itching, Chills, Fever,
Other:
CIRCLE OR UNDERLINE PERTINENT ITEMS AND FILL IN THE BLANKS
WHERE DO YOU
Room, Apartment, Brick House, Wood Frame House, Mobile Home, Basement, Other:
LIVE?
Age Of the House? (New - Less Than 10 Years, Medium - 11-30 Years, Old - Greater than 30 Years)
LOCATION:
City, Suburbs, Country, Farm, Seashore, Desert, Mountains, Near Factory, Bakery, Grain Storage, Swamp,
Poultry Yard, Barn, Other:
PROBLEMS
Bedroom, Living Room, Kitchen, Basement, Attic, Garage, Indoors, Outdoors, Other:
WORSE IN:
TYPE
OF
Forced Air, Radiator, Electric, Heat Pump, Filtered Air, Other:
HEATING:
PROBLEMS
AT Home, At Work, In Car, In Boat, Exercising, AT Beauty Shop, At School, Driving in Traffic, Sweeping,
WORSE WHEN?
House Cleaning, Making Beds, Around Fans, Around Humidifier, Around Vaporizer, Around Open Windows,
Around Heating Ducts, On Windy Days, Taking Hot or Cold Baths, Swimming in Chlorinated Water, In Musty
Places, Other:
Patient Encounter Form-AW
page 4 of 11
9/17/2013
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