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Patient Name

Date of Birth

Social History

Employed O Yes O No

Disability O Yes O No

Alcohol O Yes O No

Smoking O Yes O No

Recreational Drug Use O Yes O No

Family History

Father O Cancer O Diabetes O Back Problem O Heart Disease

O Hypertension O Stroke

Mother O Cancer O Diabetes O Back Problem O Heart Disease

O Hypertension O Stroke

Siblings O Cancer O Diabetes O Back Problem O Heart Disease

O Hypertension O Stroke

Past Medical History

Asthma O Yes O No

Hypertension O Yes O No

Diabetes O Yes O No

Congested Heart Failure O Yes O No

Chronic Obstructive Reflex Disease O Yes O No

Depression O Yes O No

Abdominal Pain O Yes O No

Neuropathy O Yes O No

Seizures O Yes O No

Sleep Apnea O Yes O No

Hepatitis O Yes O No

Headache O Yes O No

Chest Pain O Yes O No

Fibromyalgia O Yes O No

Kidney Disease O Yes O No

Cancer O Yes O No

Multiple Sclerosis O Yes O No

Anxiety Disorder O Yes O No

Arthritis O Yes O No

GERD O Yes O No

Review of Systems

Weight gain O Yes O No

Weight loss O Yes O No

Loss of appetite O Yes O No

Fever O Yes O No

Headache O Yes O No

Runny nose O Yes O No

Cough O Yes O No

Wheezing O Yes O No

Cold intolerance O Yes O No

Heat intolerance O Yes O No

Sinus congestion O Yes O No

Shortness of breath O Yes O No

Chest pain (angina) O Yes O No

Dizziness O Yes O No

Irregular Heartbeats O Yes O No

Excessive Sweating O Yes O No

Insomnia O Yes O No

Low back pain O Yes O No

Weakness O Yes O No

Weakness in arms O Yes O No

Weakness in legs O Yes O No

Cold extremities O Yes O No

Leg edema O Yes O No

Joint pain O Yes O No

Joint stiffness O Yes O No

Muscle spasms O Yes O No

Joint surgery O Yes O No

Tingling O Yes O No

Numbness in arms O Yes O No

Numbness in legs O Yes O No

Abnormal bruising O Yes O No

Abnormal bleeding O Yes O No

Enlarged Lymph Nodes O Yes O No

Vertigo O Yes O No

Tremors O Yes O No

Memory loss O Yes O No

Seizures O Yes O No

Suicidal ideation O Yes O No

Serious depression O Yes O No

Other psychiatric diagnoses O Yes O No

Psychiatric hospitalization O Yes O No

Change in vision O Yes O No

Loss of hearing O Yes O No

Blood in stool O Yes O No

Diarrhea O Yes O No

Vomiting O Yes O No

Constipation O Yes O No

Nausea O Yes O No

Difficulty swallowing O Yes O No

Change in bowel habits O Yes O No

Heartburn O Yes O No

Rash O Yes O No