Considered/Attempted suicide Poor concentration Depression Anxiety or nervousness Memory problems Immune Chronic fatigue syndrome Swollen Reaction to vaccines Ongoing infections Slow wound healing Colds/flu more than once yearly Neurological Muscle Loss of memory Numbness or tingling Easily Involuntary shaking or unsteadiness in hands Endocrine Hair Brittle nails Excessive thirst Excessive urination General fatigue Fatigue after meals Heat intolerance Cold intolerance Excessive hunger Seasonal depression Ears Impaired hearing Itching inside or outside Frequent popping Head Headaches Migraines Head injury Jaw pain/TMJ Jaw clicks when eating Nose and Sinuses Frequent head colds Sinus Nose bleeds Eyes Spots in vision Blurriness Color blindness Double vision Cataracts Eye Uncomfortable tearing
Uncomfortable dryness Glaucoma Mouth and Throat Frequent sore throat Teeth Gum bleeding/pain/disease Dental cavities Copious saliva Sore tongue/lips clicks Hoarseness Neck Goiter/enlargement in front of throat Pain or stiffness Skin Acne, Color changes Lumps Generalized itching Night sweats Urinary Frequent infections Unable to hold urine Unable to urinate Kidney stones Splitting of stream Pain with urination Frequency at night; If so, how often do you wake to urinate each night __ Respiratory Spitting of Asthma Pain on breathing Shortness of breath at night Shortness of breath Shortness of breath lying down Lung congestion/sputum Difficulty breathing Difficult taking a full deep breath Cardiovascular Heart disease High blood pressure Low blood pressure Rheumatic fever Ankle swelling Angina/chest pain Heart Heart palpitations/fluttering Intestinal
Trouble swallowing Change in thirst Change in appetite Nausea/vomiting Burning pain in stomach Jaundice Gallbladder disease Liver disease Abdominal pain or cramps Excessive belching or excess gas Black Blood in stools Bowel movement (BM) daily How often are BMs: _____________ Musculoskeletal Joint pain or stiffness Broken Muscle spasms or cramps Arthritis Weakness Sciatica Blood/Peripheral Vascular Easy bleeding/bruising Deep leg pain Varicose Anemia Cold hands Cold feet clots Reproductive Health Gonorrhea Condyloma/genital warts Genital herpes Syphilis HIV Male Reproduction Prostate disease Erectile dysfunction Delayed orgasm Premature ejaculation Testicular masses or pain Discharge or sores on penis Use condoms? Y/N Sexually active Female Reproduction Age at first menses (period)_______ Last menses __________________ Usual length of cycle (blood flow to next blood flow)_______ Irregular Painful menses Heavy flow Light flow Bleeding/spotting between periods Discharge Menopausal symptoms
Ovarian Date of last annual exam/Pap ______ Sexually active Pain during intercourse Use of birth control; if so, what type Difficulty conceiving Cervical Sexual Regular self breast Breast Breast lumps Nipple Number of pregnancies ______ Number of live births ______ Number of miscarriages _______ Are there any other health concerns that you have which have not been covered in this questionnaire? ________________________________________________________________________ ____________________________________________________ ________________ Signature Date