### HISTORY OF PRESENT AND PAST ILLNESS:

Chief Complaint: Purpose of this appointment:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date symptoms appeared:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Is this due to: Auto\_\_\_ Work\_\_\_\_ Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   Have you ever had the same or a similar condition? Yes No If yes, when and describe:\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Do you have a history of stroke or hypertension?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Women, please include information about childbirth (include dates): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   Have you been treated for any health condition by a physician in the last year? Yes No If yes, describe:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ What medications are you taking?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Do you have any Congenital Condition? \_\_\_Yes \_\_\_ No If YES, Describe \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Women: Are you

Please check off if you have or have had any of the following symptoms/conditions:

Headaches\_\_\_\_\_\_ Frequency \_\_\_\_\_\_\_\_ Loss of Balance \_\_\_\_\_\_\_\_\_\_ Neck Pain \_\_\_\_\_\_\_\_ Fainting \_\_\_\_\_\_\_\_\_\_ Stiff Neck \_\_\_\_\_\_\_\_ Loss of Smell \_\_\_\_\_\_\_\_\_\_ Sleeping Problems \_\_\_\_\_\_\_\_ Loss of Taste \_\_\_\_\_\_\_\_\_\_ Back Pain \_\_\_\_\_\_\_\_ Unusual Bowel Patterns \_\_\_\_\_\_\_\_\_\_ Nervousness \_\_\_\_\_\_\_\_ Feet Cold \_\_\_\_\_\_\_\_\_\_ Tension \_\_\_\_\_\_\_\_ Hands Cold \_\_\_\_\_\_\_\_\_\_ Irritability \_\_\_\_\_\_\_\_ Arthritis \_\_\_\_\_\_\_\_\_\_ Chest Pains/Tightness \_\_\_\_\_\_\_\_ Muscle Spasms \_\_\_\_\_\_\_\_\_\_ Dizziness \_\_\_\_\_\_\_\_ Frequent Colds \_\_\_\_\_\_\_\_\_\_ Shoulder/Neck/Arm Pain \_\_\_\_\_\_\_\_ Fever \_\_\_\_\_\_\_\_\_\_ Numbness in Fingers \_\_\_\_\_\_\_\_ Sinus Problems \_\_\_\_\_\_\_\_\_\_ Numbness in Toes \_\_\_\_\_\_\_\_ Diabetes \_\_\_\_\_\_\_\_\_\_ High Blood Pressure \_\_\_\_\_\_\_\_ Indigestion Problems \_\_\_\_\_\_\_\_\_\_ Difficulty Urinating \_\_\_\_\_\_\_\_ Joint Pain/Swelling \_\_\_\_\_\_\_\_\_\_ Weakness in Extremities \_\_\_\_\_\_\_\_ Menstrual Difficulties \_\_\_\_\_\_\_\_\_\_ Breathing Problems \_\_\_\_\_\_\_\_ Weight Loss/Gain \_\_\_\_\_\_\_\_\_\_ Fatigue \_\_\_\_\_\_\_\_ Depression \_\_\_\_\_\_\_\_\_\_ Lights Bother Eyes \_\_\_\_\_\_\_\_ Loss of Memory \_\_\_\_\_\_\_\_\_\_ Ears Ring \_\_\_\_\_\_\_\_ Buzzing in Ears \_\_\_\_\_\_\_\_\_\_ Broken Bones/Fractures \_\_\_\_\_\_\_\_ Circulation Problems \_\_\_\_\_\_\_\_\_\_ Rheumatoid Arthritis \_\_\_\_\_\_\_\_ Seizures/Epilepsy \_\_\_\_\_\_\_\_\_\_ Excessive Bleeding \_\_\_\_\_\_\_\_ Low Blood Pressure \_\_\_\_\_\_\_\_\_\_ Osteoarthritis \_\_\_\_\_\_\_\_ Osteoporosis \_\_\_\_\_\_\_\_\_\_ Pacemaker \_\_\_\_\_\_\_\_ Heart Disease \_\_\_\_\_\_\_\_\_\_ Stroke \_\_\_\_\_\_\_\_ Cancer \_\_\_\_\_\_\_\_\_\_ Ruptures \_\_\_\_\_\_\_\_ Coughing Blood \_\_\_\_\_\_\_\_\_\_ Eating Disorder \_\_\_\_\_\_\_\_ Alcoholism \_\_\_\_\_\_\_\_\_\_ Drug Addiction \_\_\_\_\_\_\_\_ HIV Positive \_\_\_\_\_\_\_\_\_\_ Gall Bladder Problems \_\_\_\_\_\_\_\_ Ulcers \_\_\_\_\_\_\_\_