**Please circle all that apply** NAME: ______

DATE: ______

ALLERGIC/ ENDOCRINE HEMATOLOGIC/ PSYCHIATRIC IMMUNOLOGIC  Excessive hair growth LYMPHATIC  Addiction to alcohol  Drug  High sugar   Anxious feelings  Environmental  Low blood sugar  Bleeding problems  Binging and purging  List ______ Perimenopausal  Bruise easily  Claustrophobia  ______symptoms  Swollen lymph nodes   ______ Overactive thyroid  Disorientation  Underactive thyroid SKIN  Emotional or mental CARDIOVASCULAR  Tired/sluggish  Acne problems abuse  Cardiovascular  Blisters  Extreme highs and lows problems or chest EYES  Burning of skin  Feelings of symptoms  Abrupt visual loss  Groups of blisters hopelessness   Blurred vision  Hair loss  Libido decrease  Elevated blood  Double vision  Skin hypersensitivity  Memory loss pressure  Excess tearing/watering  Itchy skin  Mental status change  Feet swelling from eyes  Rash  Nightmares  Heart attack  Feeling of sand in eyes  Tingling sensations  Panic attacks  Heart  Light sensitivity  Skin ulcerations   Fast heartbeat  Pain or soreness in or  Poor control  Murmur about the eyes MUSCULOSKELETAL  Poor sleep pattern  Unable to breathe  Progressive loss of  Back pain  Rape or sexual abuse easily, unless sitting vision  Joint pain victim straight or standing  Reddened eyes  Joint swelling  Suicidal thoughts upright  Transient visual loss  Muscle pain  Suicide attempt  Pacemaker  Trauma to the eye  Muscle tenderness  Neck pain RESPIRATORY CONSTITUTIONAL GASTROINTESTINAL  Asthma SYMPTOMS  Bowel habit change NEUROLOGICAL  Breathing difficulty  Appetite change or  Constipation  Aura, olfactory  Chest tightness decrease  Heartburn  Aura, visual  Flu-like symptoms   Loss of appetite  Balance problems  Recent exposure to  Fainting  Nausea  Burning tuberculosis  Feeling of spinning or   Shortness of breath  Difficulty speaking  Sleep apnea (stopping  Weight gain GENITOURINARY  breathing while asleep)  Intentional weight loss  Blood in urine  Facial tic  Snoring  Unintentional weight  Burning with urination  Focal weakness  Wheezing loss  Currently pregnant  Forgetfulness

 Partner diagnosed with  Headache HEIGHT:______EARS, NOSE, MOUTH, STD  Hypersensitivity THROAT  Excessive amounts of WEIGHT:______ Difficulty with hearing  Inability to produce urine language  Difficulty with  Urinary frequency ADDITIONAL COMMENTS: swallowing  Inability to understand  Urinary incontinence language ______ Ear pain  Urinary urgency  Inability to read ______ Lost  Urine retention  Inability to write ______ Ringing in ears  Muscle weakness ______ Sinus problems  Numbness ______ Sound sensitivity  Paralysis ______ Seizure ______

SMOKING  Sleepiness ______ No ______ Slurred speech ______ Yes ______ Tingling ______ How Much  Tremors ______ ______ Uncontrolled ______movements