Date MM slash DD slash YYYY Last First HEALTH HISTORYCheck the symptoms you are currently having or had in the past year. GENERAL Chills Depression Dizziness Fainting Fever Forgetfulness Headache Sleep loss Weight loss Nervousness Sweats SKIN Bruise easily Hives Itching Changes in Mole Rash GASTROINTESTINAL Bloating Blood in stool Blood in vomit Bowel changes Constipation Diarrhea Excessive hunger Gas Hemorrhoids Increase in appetite Loss of appetite Indigestion Nausea Rectal bleeding Stomach pain vomiting CARDIOVASCULAR Chest pain High blood pressure Low blood pressure Irregular heart beat Swelling of ankles Poor circulation Rapid heart beat PAIN OR NUMBNESS Arms back Feet Fingers Hands Hips Legs Neck Shoulders HEENT Bleeding gums Blurred Vision Difficulty swallowing Double vision Ear ache Ear discharge Eye infection Hoarseness Loss of hearing Nose bleeds Persistent cough Ringing in the ears Sinus problems Sore throat Vision halos Vision flashes MEN ONLY Erection difficulties Penis discharge Lump in testicles/breast Other WOMEN ONLY Last menstrual period Last mammogram Last pap smear Abnormal pap smear Yes No Please check conditions that apply to you (information is CONFIDENTIAL) Aids Alcoholism Anemia Anorexia Appendicitis Arthritis Asthma Bleeding disorder Bronchitis Bulimia Cancer Cataracts Chicken pox diabetes Drug dependency Emphysema epilepsy Glaucoma Goiter Gonorrhea Gout Hepatitis Hernia Herpes High Cholesterol HIV Positive Kidney disease Lung disease Measles Migraines Mononucleosis Mumps Pacemaker Pneumonia Polio Prostrate problems Psychiatric care Rheumatic fever Stroke Suicide attempt Thyroid problems Tuberculosis Vaginal infections Venereal disease Vaccinations DateLocationFlu Vaccine MM slash DD slash YYYY Hepatitis A MM slash DD slash YYYY Hepatitis B MM slash DD slash YYYY HPV MM slash DD slash YYYY Pneumococcal MM slash DD slash YYYY Meningococcal MM slash DD slash YYYY Other MM slash DD slash YYYY
