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MEDICAL HISTORY Circle the nmber beside each symptom you have now or have had within the last few months. ( 1 = mildly or occassionally, 2 = severe or frequent ) If you had a problem in the past, but NOT within the last few months, put a star or checkmark in front of the word. if unsure, write a question mark.
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Weakness or Paralysis Tired a lot Weight Change >10 lbs Change in Appetite Sensitivity to Cold or Heat Fever Night Sweats Hot FLashes Skin Problems Change in Nails or Hair Headaches Easy Bleeding Easy bruising Vision Change Eye Pain Infected Eyes Glaucoma Ringing in ears Discharge from Ears Ear Pain Hearing Loss Frequent Nose Bleeds Frequent Colds Sinus Problems Loss of Smell Persistent Hoarseness Sore Throat Sore Tongue or Gums Difficulty Swallowing Chronic cough Difficulty Breathing Productive Cough Wheezing Tuberculosis Chest Pain or Discomfort Swelling of Hands, Feet, Palpitations or Fluttering |
1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 N or Y 1 or 2 . 1 or 2 . 1 or 2 |
Leg Cramps Enlarged Veins Blood Pressure Poor Circulation Dizziness Fainting Heartburn Frequent Belching Abdominal Cramping Nausea Vomiting Diarrhea Constipation Rectal Bleeding Black Tarry Stools Diverticulitis Dark Urine Frequent Urination Increase in Thirst Painful Urination Leakage of Urine Blood in Urine Bladder Infections lack of Sex Drive Hemorrhoids backaches Joint Pain or Stifness Swollen Joints Diabetes, Type: Muscle Cramps or Spasms Sleeplessness Seizures AIDS/HIV+ |
1 or 2 1 or 2 . 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 . 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 Y or N |
Broken Bones Liver Cirrhosis Liver Hepatitis Measles Mumps Chicken Pox Mononucleosis STD's Polio Hernia Stroke Depression Memory Loss Thyroid Disease Cancer, type: Anything else:
Men Only:
Women Only: Clotting with Cycle Heavy Flow Cramping / Pain 1st Day of Last Period: Length of Cycle = __________________days Cycle is: � Regular � Irregular Date of Last Pelvic Exam: Breast Lumps or Discharge Any chance you may be pregnant Number of Pregnancies / # of Full Term Births |
N or Y N or Y N or Y N or Y N or Y N or Y N or Y N or Y N or Y N or Y 1 or 2 1 or 2 1 or 2 N or Y . . . .
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