Do you have a history of:

                                    

Cancer                                           Yes No                            Allergies/Asthma Yes No

Diabetes                                        Yes No                            Headaches/Migraines Yes No

High Blood Pressure                   Yes No                            Bronchitis                                               Yes No

Heart Disease                               Yes No                            Kidney Disease Yes No   

Angina/Chest Pain                       Yes No                            Rheumatic Fever Yes No

Stroke                                              Yes No                            Ulcers                                                    Yes No

Osteoarthritis                                  Yes No                            Seizures                                                 Yes No

Osteoporosis                                  Yes No                            Sexually Transmitted Disease           Yes No

Rheumatoid arthritis                      Yes No  

In the past 3 months have you had or do you experiences: Are You Currently:

A change in your health Yes No Pregnant Yes No

Nausea/Vomiting/Indigestion Yes No Depressed Yes No

Fever/chills/sweats Yes No Under Stress Yes No

Unexplained weight change Yes No

Numbness or tingling Yes No Are Your Symptoms: (check one)

Changes in bowel or bladder function Yes No ___Getting Worse___The Same___Improving

Change in Appetite Yes No How are you able to sleep at night (check one)

Difficulty Swallowing Yes No ___Fine___Moderate difficulty___Only with Med's

Shortness of Breath Yes No

Urinary Tract Infection Yes No Do you have a problem with:

Dizziness Yes No Check All That Apply

Upper Respiratory Infection Yes No _____Hearing _____Vision_____Speech _____Communication

Do you or have you in the past smoked tobacco: ___Yes ___No If Yes, ____Packs/Wk X_____Year.

Do you drink alcoholic beverages: ___ Yes___No If Yes, _____Drinks/Wk X_____Year.

Date of Last Exam:______________________ Medications ____________________________

________________________________________

Patient Signature: ___________________________ Date:________________________________