Health questions.qxd

PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR HEALTH:
Constitutional
Integumentary (skin, breast)
Good general health _________________________No Rash or itching _______________________________No Recent weight change _______________________No Change in skin color __________________________No Fever ________________________________________No Varicose veins ________________________________No Fatigue ______________________________________No Breast pain or lump ___________________________No Headaches __________________________________No Breast discharge______________________________No Neurological
Eye disease or injury __________________________No Frequent/recent headaches __________________No Wear glasses/contacts ________________________No Light-headed/dizzy ___________________________No Blurred/double vision _________________________No Convulsions/seizures __________________________No Glaucoma ___________________________________No Numbness/tingling ____________________________No Eye surgery ___________________________________No Tremors ______________________________________No Ear/Nose/Mouth/Throat
Stroke/paralysis _______________________________No Hearing loss/ringing ___________________________No Head injury ___________________________________No Earaches or drainage_________________________No Psychiatric
Chronic sinus problems _______________________No Memory loss/confusion________________________No Nose bleeds __________________________________No Nervousness __________________________________No Sore throat/voice change ____________________No Depression ___________________________________No Swollen glands in neck ________________________No Insomnia _____________________________________No Cardiovascular
Endocrine
Heart trouble _________________________________No Gland/hormone ______________________________No Chest pain ___________________________________No Thyroid disease _______________________________No Palpitations___________________________________No Diabetes _____________________________________No Shortness of breath ___________________________No Excessive thirst/urination ______________________No Swelling of feet/ankles/hands _________________No Heat/cold intolerance ________________________No Respiratory
Hematologic/Lymphatic
Chronic/frequent coughs _____________________No Slow to heal cuts _____________________________No Spitting up blood _____________________________No Bleeding/bruising tendency ___________________No Asthma or wheezing __________________________No Anemia ______________________________________No Gastrointestinal
Phlebitis ______________________________________No Loss of appetite ______________________________No Past transfusion _______________________________No Change in bowel movement _________________No Enlarged glands ______________________________No Nausea/vomiting _____________________________No Allergic/Immunologic
Frequent diarrhea ____________________________No Constipation _________________________________No Penicillin/antibiotic __________________________No Rectal bleeding/blood in stool ________________No Novocaine or other anesthetics ______________No Abdominal pain/heart burn ___________________No Tetanus antitoxin or other serum ______________No Peptic ulcer __________________________________No Iodine, methiolate or other __________________No Genitourinary
Other drugs: _____________________________________________ Frequent urination ____________________________No _________________________________________________________ Blood in urine_________________________________No Known food allergies _____________________________________ Kidney stones ________________________________No _________________________________________________________ Sexual difficulties _____________________________No Male testicle pain ____________________________No FULL NAME (PLEASE PRINT):
Use of Flomax ________________________________No _________________________________________________________ Musculoskeletal
DATE OF BIRTH:
Joint pain ____________________________________No _________________________________________________________ Joint stiffness or swelling _______________________No Muscle pain/cramps __________________________No PLEASE SIGN:
Back pain ____________________________________No Cold extremities ______________________________No _________________________________________________________ Difficulty in walking ___________________________No _________________________________________________________

Source: http://www.terrelwilliamsmd.com/documents/health_questionaire.pdf