Headaches / yes / no / past / Head Injury / yes / no / past
Migraines / yes / no / past / Hair Loss / yes / no / past
Foggy / yes / no / past / Twitching Face / yes / no / past
Dry Hair / yes / no / past / Brittle/Breaking Hair / yes / no / past
Vertigo / yes / no / past / Dizziness / yes / no / past
Numb/Tingle / yes / no / past / Memory Loss / yes / no / past

Eyes

Dryness / yes / no / past / Blurriness / yes / no / past
Redness / yes / no / past / Pain / yes / no / past
Itchy / yes / no / past / Tearing / yes / no / past
Glasses/Contacts / yes / no / past / Cataracts / yes / no / past
Floaters / yes / no / past / Glaucoma / yes / no / past
Pressure / yes / no / past / Twitching / yes / no / past

Ears

Poor Hearing / yes / no / past / Ringing / yes / no / past
Excess Wax / yes / no / past / Infections / yes / no / past
Nose/Sinus
Frequent colds / yes / no / past / Sneezing / yes / no / past
Congestion / yes / no / past / Runny Nose / yes / no / past
Sinus Infections / yes / no / past / Loss of Smell / yes / no / past
Nose Bleeds / yes / no / past / Dry Nose/Sinus / yes / no / past
Hay fever / yes / no / past / Dry/Cracked Lips / yes / no / past

Mouth / Throat

Cavities / yes / no / past / Gum Problems / yes / no / past
Sore lips/gums / yes / no / past / Teeth Grinding / yes / no / past
Jaw/TMJ Pain / yes / no / past / Lump in Throat / yes / no / past
Sore throat / yes / no / past / Difficult Swallow / yes / no / past
Hoarse Voice / yes / no / past / Cold Sores / yes / no / past
Dry Mouth / yes / no / past / Bad Breath / yes / no / past

Neck

Lumps / yes / no / past / Swollen Glands / yes / no / past
Goiter / yes / no / past / Pain/Stiffness / yes / no / past
Difficulty Swallowing / yes / no / past / Dry Throat / yes / no / past

Respiratory

Asthma / yes / no / past / Cough Mucus/Phlegm / yes / no / past
Wheezing / yes / no / past / Cough Blood / yes / no / past
Short of Breath / yes / no / past / Frequent Sighing / yes / no / past
Cough / yes / no / past / Pneumonia / yes / no / past
Nasal Drip / yes / no / past / Seasonal Allergies / yes / no / past
Pain w/ Breath / yes / no / past / Side Discomfort / yes / no / past
Weak Voice / yes / no / past

Cardiovascular

Heart Disease / yes / no / past / High Blood Pres / yes / no / past
Murmur / yes / no / past / Low Blood Pres / yes / no / past
Palpitations / yes / no / past / Ankle/Leg Swell / yes / no / past
Fainting / yes / no / past / Chest Pain/tight / yes / no / past
Pounding Heart / yes / no / past

Blood / Vascular

Poor Circulation / yes / no / past / Cold Hands/Feet / yes / no / past
Blood Clots / yes / no / past / Bruise/Bleed Easy / yes / no / past
Anemia / yes / no / past / Varicose Veins / yes / no / past
Spider Veins / yes / no / past / Numb Hands/Feet / yes / no / past
Fixed/Stabbing Pain / yes / no / past

Gastrointestinal

Heartburn / yes / no / past / Hemorrhoids / yes / no / past
Ulcer / yes / no / past / Flatulence / yes / no / past
Diarrhea / yes / no / past / Belching / yes / no / past
Smelly BM / yes / no / past
Constipation / yes / no / past / Pain/Cramping / yes / no / past
Pain w/ BM / yes / no / past / Nausea / yes / no / past
Blood with BM / yes / no / past / Vomiting / yes / no / past
Undigested Food / yes / no / past / Frequent BM / yes / no / past
Recent Change in / Gallstones / yes / no / past
- Appetite / yes / no / past / Loud Stomach / yes / no / past
- Thirst / yes / no / past / Hiccoughs / yes / no / past
- BM / yes / no / past / Bloating / yes / no / past
Cravings / yes / no / past / sugar? / salt? / other:
Excess Thirst / yes / no / past / Lack of Thirst / yes / no / past
Excess Hunger / yes / no / past / Lack of Appetite / yes / no / past

Urinary

Bladder Infections / yes / no / past / Frequency / yes / no / past
Kidney Infections / yes / no / past / Urgency / yes / no / past
Incontinence / yes / no / past / # of times @ night / 1 / 2 / 3+
Stones / yes / no / past / Pain/Burning / yes / no / past
Blood in Urine / yes / no / past / Difficult urination / yes / no / past
Cloudy Urine / yes / no / past / Strong Odor / yes / no / past
Dark/Yellow/Brown / yes / no / past / Light/Clear / yes / no / past
Large amounts / yes / no / past / Small Amount / yes / no / past

Skin

Rashes / yes / no / past / Warts / yes / no / past
Hives / yes / no / past / Acne / yes / no / past
Itching / yes / no / past / Shingles/ Herpes / yes / no / past
Lumps / yes / no / past / Sweat Easily / yes / no / past
Sweaty hands/feet / yes / no / past / Body Odor / yes / no / past
Discoloration / yes / no / past / Oily Complexion / yes / no / past
Pale Complexion / yes / no / past / Circles under Eyes / yes / no / past
Red Complexion / yes / no / past

Neurological

Seizures / yes / no / past / Sciatica / yes / no / past
Paralysis / yes / no / past / Autism / yes / no / past
Numb/Tingle / yes / no / past / ADD/ADHD / yes / no / past

Endocrine

Night Sweats / yes / no / past / Heat/Cold Intolerant / yes / no / past
Hot Hands/Feet / yes / no / past / Thyroid Condition / hyper / hypo

Emotional Health

Quick tempered / yes / no / past / Fearful / yes / no / past
Easily stressed / yes / no / past / Easily Frightened / yes / no / past
Depressed / yes / no / past / Worry / yes / no / past
Anxious / yes / no / past / Forgetful / yes / no / past
Sadness / yes / no / past / Heart Pounding / yes / no / past
Energetic / yes / no / past / Positive / yes / no / past
Well Rested / yes / no / past / Prefer Quiet / yes / no / past

Reproductive Health

Women

Age Menses Began / Age Menses Ended
# of Days of Flow / # of days in Cycle
# pregnancies / Cycles Regular? / yes / no / past
# live births / Midcycle bleeding / yes / no / past
# miscarriages / Pain with menses / yes / no / past
Difficult conception / yes / no / past / PMS / yes / no / past
Vaginal Discharge / yes / no / past / Breast Tenderness / yes / no / past
color / Breast Lumps / yes / no / past
odor / yes / no / past / Nipple Discharge / yes / no / past
Vaginal Dryness / yes / no / past / Excess Flow / yes / no / past
Sexually Active / yes / no / past / Clots in Menses / yes / no / past
Painful Intercourse / yes / no / past / Blood Color / yes / no / past
Difficulties w/ Sex / yes / no / past / Birth Control / yes / no / past
STDs / yes / no / past / type
Sex Drive / low / avg / high / Last PAP/GYNE

Men

Hernias / yes / no / past / Discharge / yes / no / past
Testicular Pain / yes / no / past / if yes, color / yes / no / past
Testicular Masses / yes / no / past / Sores / yes / no / past
Vericocele / yes / no / past / STD's / yes / no / past
Groin/Low Abd Pain / yes / no / past / Infertility / yes / no / past
Pain Refer? / yes / no / past / Sexually Active / yes / no / past
Enlarged Prostate / yes / no / past / Sexual Difficulties / yes / no / past
Sex Drive / Low / Avg / High / Sexual Orientation / Hetero- / Homo- / Bi-
Children / yes / no / # / Painful Intercourse / yes / no / past

Male Infertility

How Long? / Erection with Masturbation? / yes / no / past
Previous Pregnancy? / yes / no / Premature Ejaculation? / yes / no / past
Able to achieve erection? / yes / no / Delayed Ejaculation? / yes / no / past
Able to maintain erection / yes / no
Erection upon waking / yes / no