Name *

First Name

Last Name

General

Weight loss

Weight gain

Weakness

Fever

Chills

Night Sweats

Decreased Appetite

Skin

Rash

Non-Healing Wounds

Bruising

Eyes

Blurred Vision

Loss of Vision

Glaucoma

Ears

Deafness

Ringing

Discharge

Pain

Nose

Bleeding

Drainage

Obstruction

Congestion

Mouth

Bleeding Gums

Sore Areas

Open Wounds

Loose Teeth

Dentures

Throat

Recent Sore Throat

Difficulty Swallowing

Hoarseness

Neck

Pain

Stiffness

Breasts

Discharge

Lumps

Pain

Bleeding

Lungs

Cough

Sputum Change

Coughing of blood

Shortness of breath

PE

Heart

Pain in chest

Swelling of legs

History of Rheumatic Fever

Fluttering of heart

Heart murmur

Vascular

Pain or Cramps in legs after walking

DVT (Blood clots)

Gastrointestinal

Nausea

Vomiting

Vomiting of blood

Heartburn/GERD

Blood in stool

Dark/Tarry stool

Hemorrhoids

Urinary Tract

Pain on urination

Dribbling

Loss of urine

Blood in urine

Dark Urine

Musculoskeletal

Broken bones

Arthritis

Stiff joints

Muscle weakness

Neurological

Seizures

Numbness

Paralysis

Headache

Stroke

Psychiatric

Depression

Nervousness

Altered sleep (more/less)

Bipolar

Heart Disease

MI

Bypass

Pacemaker

AICD

Other

Lung Disease

COPD

Asthma

Sleep Apnea (OSA)

Other

Cancer

Lung

Colon

Cervical

Breast

Skin

Other

Diabetes

Yes

No

History of any of the following in your family?

Heart Disease

Diabetes

Lung Disease

Cancer