May we leave a brief message?
Have you ever been treated for any of the following medical conditions?
Have you ever been hospitalized overnight?
Have you ever had surgery?
Will be reviewed by clinic staff. (Please bring your bottles with you or a complete list of everything you take on a regular basis.)
Do you take any supplements (calcium/vitamin D/fish oil/multivitamin)?
Please list any known medical problems for the relatives listed below: For example: diabetes, breast/colon/ovarian/ prostate cancer, heart attacks, high blood pressure, alcohol abuse, depression, skin cancer, osteoporosis.
Any trouble sleeping?
Do you eat out more than twice a week?
Are you retired?
Any major stresses in your life?
Do you feel you ever have been abused (verbally, physically, or sexually?
Do you wear seatbelts/helmets?
Do you wear sunscreen?
Do you have an eye exam at least every two years?
Do you have a dental exam at least yearly?
General Symptoms: Fever, unexplained tiredness, swollen glands, excessive thirst, feeling unusually hot or cold, easy bruising or bleeding, passing out
Eyes: Vision loss, eye pain, blurred vision
Ears/Nose/Mouth & Throat: Sore throat, runny nose, hearing loss, problems with mouth, voice changes
Breasts: Lumps, skin changes, nipple dis- charge
Lungs & Heart: Chest pain/pressure, irregular heart beat, cough, wheezing, breathing trouble
Skin: Rashes, changing moles, changes in hair/skin/nails
Neurological: Unusual or new headaches, weak- ness or numbness, falling
Abdomen: Nausea, vomiting, pain, heartburn, diarrhea, constipation, bloody stools
Sleep: Difficulty falling asleep, frequent awakening
Musculoskeletal: Joint/muscle pain, muscle weak- ness
Mood: Worry too much, felt down and depressed in the last two weeks, loss of desire to do things you used to enjoy, thoughts of self harm or suicide
Men Only: Difficulty starting or weak stream, difficulty getting/maintaining erections, feeling like bladder won’t empty, getting up at night to urinate, testicular pain/lumps, possible sexually transmitted infections
Women Only: Heavy periods, bleeding after menopause, sexual concerns, unusual vaginal discharge, possible sexually transmitted infections, severe pain with periods, leaking urine
Still having periods?
Hysterectomy:
Diabetes in pregnancy?
Have you ever had an abnormal pap or colposcopy?
Other: List any symptoms not mentioned
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