Name: _____________________________________ Today’s Date: __________________________
For new patients, established patients who may be having a new problem, or our patients who we
haven’t seen for a while, we need to update our records as to your general medical health. In each area,
if you are not having any difficulties, please check “No Problems.” If you are experiencing any of the
symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or explain any that may not be listed. If
you have any questions about this, please ask one of the technicians, or your doctor.
Const. (Health in General) No Problems Lack of energy, unexplained weight gain or
weight loss, loss of appetite, fever, night sweats, pain in jaws when eating, scalp tenderness, prior
diagnosis of cancer. Other: _______________________________________________________________
Ears, Nose, Mouth & Throat No Problems Difficulty with hearing, sinus problems, runny
nose, post-nasal drip, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial
pain or numbness. Other: _________________________________________________________________
C-V (Heart & Blood Vessels) No Problems Irregular heartbeat, racing heart, chest pains,
swelling of feet or legs, pain in legs with walking. Other: _______________________________________
Resp. (Lungs & Breathing) No Problems Shortness of breath, night sweats, prolonged
cough, wheezing, sputum production, prior tuberculosis, pleurisy, oxygen at home, coughing up blood,
abnormal chest x-ray. Other: _______________________________________________________________
GI (Stomach & Intestines) No Problems Heartburn, constipation, intolerance to certain
foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained
change in bowel habits, incontinence. Other: ________________________________________________
GU (Kidney & Bladder) No Problems Painful urination, frequent urination, urgency,
prostate problems, bladder problems, impotence. Other: ______________________________________
MS (Muscles, Bones, Joints) No Problems Joint pain, aching muscles, shoulder pain,
swelling of joints, joint deformities, back pain. Other: ___________________________________________
Integ. (Skin, Hair & Breast) No Problems Persistent rash, itching, new skin lesion, change
in existing skin lesion, hair loss or increase, breast changes. Other: ______________________________
Neurologic (Brain & Nerves) No Problems Frequent headaches, double vision, weakness,
change in sensation, problems with walking or balance, dizziness, tremor, loss of consciousness,
uncontrolled motions, episodes of visual loss. Other: __________________________________________
Psychiatric (Mood & Thinking) No Problems Insomnia, irritability, depression, anxiety,
recurrent bad thoughts, mood swings, hallucinations, compulsions. Other: _______________________
Endocrinologic (Glands) No Problems Intolerance to heat or cold, menstrual
irregularities, frequent hunger/urination/thirst, changes in sex drive. Other: _______________________
Hematologic (Blood/Lymph) No Problems Easy bleeding, easy bruising, anemia, abnormal
blood tests, leukemia, unexplained swollen areas. Other: _______________________________________
Allergic/Immunologic No Problems Seasonal allergies, hay fever symptoms, itching,
frequent infections, exposure to HIV. Other: ___________________________________________________