Are you menopausal? Yes_____ No_____ If yes, age of menopause Do you currently take hormone replacement? Yes___ No___ If yes, what type and for how long? ______ Estrogen Ogen Estrace Premarin Progesterone Provera Other ________________________________ FAMILY HEALTH HISTORY Please indicate current and past history to the best of your knowledge REVIEW OF SYMPTOMS Check (√) those items that applied to you in the past. Circle those that presently apply General Fever Chills/Cold all over Aches/Pains General Weakness Difficulty sweating Excessive Sweating Swollen Glands Cold hands & Feet Fatigue Difficulty falling asleep Sleepwalker Nightmares No dream recall Early waking Daytime sleepiness Distorted vision SKIN: Cuts heal slowly Bruise easily Rashes Pigmentation Changing Moles Calluses Eczema Psoriasis Dryness/cracking skin Oiliness Itching Acne Boils Hives Fungus on Nails Peeling Skin Shingles Nails Split White Spots/Lines on Nails Crawling Sensation Burning on Bottom of Feet Athletes Foot Cellulite Bugs love to bite you Bumps on back of arms & front of thighs Skin cancer Strong body odor Is your skin sensitive to: Sun Fabrics Detergents Lotions/Creams HEAD:
Poor Concentration Confusion Headaches: After Meals Severe Migraine Frontal Afternoon Occipital Afternoon Daytime Relieved by: Eating Sweets Concussion/Whiplash Mental sluggishness Forgetfulness Indecisive Face twitch Poor memory Hair loss EYES: Feeling of sand in eyes Double vision Blurred vision Poor night vision See bright flashes Halo around lights Eye pains Dark circles under eyes Strong light irritates Cataracts Floaters in eyes Visual hallucinations EARS: Aches Discharge/Conjunctivitis Pains Ringing Deafness/Hearing loss Itching Pressure Hearing aid Frequent infections Tubes in ears Sensitive to loud noises Hearing hallucinations NOSE/SINUSES Stuffy Bleeding Running/Discharge Watery nose Congested Infection Polyps Acute smell Drainage Sneezing spells Post nasal drip No sense of smell Do the change of seasons tend to make your symptoms worse? Yes/No If yes, is it worse in the: Spring Summer Fall Winter MOUTH: Coated tongue Sore tongue Teeth problems Bleeding gums Canker sores TMJ Cracked lips/ corners Chapped lips Fever blisters Wear dentures Grind teeth when sleeping Bad breath Dry mouth THROAT: Mucus Difficulty swallowing Frequent hoarseness Tonsillitis Enlarged glands Constant clearing of throat Throat closes up NECK: Stiffness Swelling Lumps Neck glands swell CIRCULATION/RESPIRATION: Swollen ankles Sensitive to hot
Sensitive to cold Extremities cold or clammy Hands/Feet go to sleep/numbness/tingling High blood pressure Chest pain Pain between shoulders Dizziness upon standing Fainting spells High cholesterol High triglycerides Wheezing Irregular heartbeat Palpitations Low exercise tolerance Frequent coughs Breathing heavily Frequently sighing Shortness of breath Night sweats Varicose veins/spider veins Mitral valve prolapse Murmurs Skipped heartbeat Heart enlargement Angina pain Bronchitis/Pneumonia Emphysema Croup Frequent colds Heavy/tight chest Prior heart attack ? When___/___/_____ Phlebitis GASTROINTESTINAL Peptic/Duodenal Ulcer Poor appetite Excessive appetite Gallstones Gallbladder pain Nervous stomach Full feeling after small meal Indigestion Heartburn Acid Reflux Hiatal Hernia Nausea Vomiting Vomiting blood Abdominal Pains/Cramps Gas Diarrhea Constipation Changes in bowels Rectal bleeding Tarry stools Rectal itching Use laxatives Bloating Belch frequently Anal itching Anal fissures Bloody stools Undigested food in stools KIDNEY/URINARY TRACT: Burning Frequent urination Blood in urine Night time urination Problem passing urine Kidney pain Kidney stones Painful urination Bladder infections Kidney infections Syphilis Bedwetting Have trichomonas WOMEN’S HISTORY (for women only) Fibrocystic breasts Lumps in breast Fibroid Tumors/Breast Spotting Heavy periods Fibroid Tumors/Uterus WOMEN’S HISTORY (for women only) Painful periods Change in period Breast soreness before period Endometriosis Non-period bleeding Breast soreness during period Vaginal dryness Vaginal discharge Partial/total hysterectomy Hot flashes Mood swings Concentration/Memory Problems Breast cancer Ovarian cysts
Pregnant Infertility Decreased libido Heavy bleeding Joint pains Headaches Weight gain Loss of bladder control Palpitations MEN’S HISTORY (for men only) Have you had a PSA done? Yes _____ No _____ PSA Level: 0 – 2 2 – 4 4 – 10 >10 Prostate enlargement Prostate infection Change in libido Impotence Diminished/poor libido Infertility Lumps in testicles Sore on penis Genital pain Hernia Prostate cancer Low sperm count Difficulty obtaining erection Difficulty maintaining an erection Nocturia (urination at night) How many times at night? ____ Urgency/Hesitancy/Change in Urinary Stream Loss of bladder control JOINT/MUSCLES/TENDONS Pain wakes you Weakness in legs and arms Balance problems Muscle cramping Head injury Muscle stiffness in morning Damp weather bothers you Emotional: Convulsions Dizziness Fainting Spells Blackouts/Amnesia Had prior shock therapy Frequently keyed up and jittery Startled by sudden noises Anxiety/Feeling of panic Go to pieces easily Forgetful Listless/groggy Withdrawn feeling/Feeling ‘lost’ Had nervous breakdown Unable to concentrate/short attention span Vision changes Unable to reason Considered a nervous person by others Tends to worry needlessly Unusual tension EMOTIONAL (CONTINUED) Frustration Emotional numbness Often break out in cold sweats Profuse sweating Depressed Previously admitted for psychiatric care Often awakened by frightening dreams Family member had nervous breakdown Use tranquilizers Misunderstood by others Irritable/ Feeling of hostility/volatile or aggressive Fatigue Hyperactive Restless leg syndrome Considered clumsy Unable to coordinate muscles Have difficulty falling asleep Have difficulty staying asleep Daytime sleepiness Am a workaholic Have had hallucinations Have considered suicide Have overused alcohol Family history of overused alcohol Cry often Feel insecure Have overused drugs