FAMILY HISTORY What medical problems do people in your family have? Family Member Medical Problems Mother: ☐ Diabetes (sugar) ☐ High blood pressure ☐ Heart problems ☐ Cancer ☐ other: Father: ☐ Diabetes (sugar) ☐ High blood pressure ☐ Heart problems ☐ Cancer ☐ other: Sisters: ☐ Diabetes (sugar) ☐ High blood pressure ☐ Heart problems ☐ Cancer ☐ other: Brothers: ☐ Diabetes (sugar) ☐ High blood pressure ☐ Heart problems ☐ Cancer ☐ other: HISTORY OF MEDICAL CONDITIONS Have you ever had any of the following conditions? (Check all that apply) ☐ Anemia (low iron blood) ☐ Asthma (wheezing) ☐ Diabetes (sugar) ☐ Heart Trouble ☐ Hemorrhoids (piles) ☐ Cancer ☐ Hepatitis (yellow jaundice) ☐ Tuberculosis (TB) ☐ Liver Trouble ☐ Pneumonia ☐ Rheumatic Fever ☐ Ulcers ☐ Stroke ☐ High Blood Pressure ☐ Skin problems ☐ Depression (feeling down or blue) ☐ Epilepsy (fits, seizures) ☐ Anxiety (nerves, panic attacks) ☐ VD, STD (syphilis, gonorrhea, chlamydia, HIV) ☐ Other
REVIEW OF SYMPTOMS Sleeping Do you feel tired a lot? ☐ Yes ☐ No Do you have trouble falling or staying asleep? ☐ Yes ☐ No Do you have other problems with sleep? ☐ Yes ☐ No Eating Have you lost your appetite recently? ☐ Yes ☐ No Have you lost weight in the last year without trying? ☐ Yes ☐ No Do you eat too much or have you gained weight recently? ☐ Yes ☐ No Do you have other problems with eating? ☐ Yes ☐ No Throat Do you have sore throats a lot? ☐ Yes ☐ No Do you have other problems with your throat? ☐ Yes ☐ No Ears Do you have trouble hearing? ☐ Yes ☐ No Do you wear a hearing aid? ☐ Yes ☐ No Do you have constant ringing or noises in your ears? ☐ Yes ☐ No Do you have other problems with your ears? ☐ Yes ☐ No Back Do you have back pain? ☐ Yes ☐ No Do you have any other problems with your back? ☐ Yes ☐ No Eyes Do you have trouble with your vision or seeing? ☐ Yes ☐ No Do you wear glasses or contacts? ☐ Yes ☐ No Do you have other problems with your eyes? ☐ Yes ☐ No Nose and Sinuses Do you have a runny or stopped up nose a lot? ☐ Yes ☐ No Do you have other problems with your nose or sinuses? ☐ Yes ☐ No Teeth and Mouth Do you have sore or bleeding gums? ☐ Yes ☐ No Do you wear plates or false teeth? ☐ Yes ☐ No Do you have other problems with your teeth and mouth? ☐ Yes ☐ No REVIEW OF SYMPTOMS CONTINUED
Heart or Breathing Do you ever have pain/tightness in your chest when working or exercising? ☐ Yes ☐ No Do you wake up at night with trouble breathing? ☐ Yes ☐ No Do you have a racing or skipping heartbeat at times? ☐ Yes ☐ No Do you have other heart or breathing problems? ☐ Yes ☐ No Bowel Movements Do you have bowel movements (poop) that are black, like tar, or bloody? ☐ Yes ☐ No Do you have any other problems with your bowel movements (poop)? ☐ Yes ☐ No Peeing and Kidney Stones Do you have trouble passing your urine (peeing) ☐ Yes ☐ No Does it burn when you pass urine (pee)? ☐ Yes ☐ No Do you have to pee more than 2 times a night? ☐ Yes ☐ No Do you leak urine (pee)? ☐ Yes ☐ No Have you ever passed kidney stones? ☐ Yes ☐ No Do you have any other problems with your peeing? ☐ Yes ☐ No Joints Do you have swollen or painful joints? ☐ Yes ☐ No Do you have any other problems with your joints? ☐ Yes ☐ No REVIEW OF SYMPTOMS CONTINUED Head, Balance, Fever and Weakness Do you have frequent or severe headaches? ☐ Yes ☐ No Have you ever fainted (passed out)? ☐ Yes ☐ No Have you lost your balance and fallen recently? ☐ Yes ☐ No Do you have weakness in any part of your body? ☐ Yes ☐ No