Last Name First Name MI
Address
City State Zip Country
E-Mail Address
URL Address
Telephone Number
Weight Height Age Sex Gender I. WHAT IS YOUR MEDICAL COMPLAINT:
II. HAVE YOU EVER HAD: (check each item) YES / NO {if YES, when and how frequently, when was the last ocurrance}
Yes No
1. Scarlet fever 2. Diphtheria 3. Rheumatic Fever 4. Chronic or Frequent Colds 5. Sinusitis 6. Tuberculosis 7. Heart Murmur / Palpitations 8. Heart Attack 9. Other Heart Condition 10. Stomach, Liver, Intestinal Problem 11. Gall Bladder / Gall Stone Problem 12. Jaundice 13. Reaction to Serum, Drugs, Medicine 14. Tumor, Growth, Cyst, Cancer 15. Piles or Rectal Disease 16. Kidney Stone or Blood in Urine 17. Sugar or Albumin in Urine 18. Sexually Transmitted Disease 19. Any Drug or Narcotic Habit 20. Excessive Drinking Habit 21. Worn a Brace or Back Support 22. Exposure to AIDS / HIV/ HEPITITUS 23. Worn Glasses 24. Eye Problems 25. Ear, Nose, Throat ProblemsIII. FEMALES ONLY: HAVE YOU EVER:
Yes No 26. Been Pregnant 27. Had a Vaginal Discharge 28. Been Treated for a Female Disorder 29. Had a Painful Menstruation 30. Had an Irregular Menstruation 31. Age at Onset of Menstruation 32. Interval Between Periods 33. Duration of Periods 34. Date of Last Period 35. Quantity of Menstruation - normal , Excessive , Scanty IV. HAVE YOU EVER HAD OR DO YOU NOW HAVE
No / Seldom / Frequently {when did it first appear, and how often} CARDIOVASCULAR 36. Shortness of Breath 37. Ankle Swelling 38. High Blood Pressure 39. Rapid Heart Beat 40. Irregular Heart Beat 41. Dizziness 42. Fainting Spells 43. Chest Pains or Pressure 44. Leg Cramps No / Seldom / Frequently RESPIRATORY 45. Cough 46. Coughed up Blood 47. Hoarseness 48. Sore Throat 49. Sneezing 50. Hay Fever 51. Nose Bleeds 52. Chest Pain 53. Asthmatic Wheezing 54. Pneumonia No / Seldom / Frequently GENITOURINARY 55. Back Pain 56. Frequent Urination 57. Painful Urination 58. Pain in the Testicles 59. Bloody or Other Discharge 60. Loss of Sexual Potency No / Seldom / Frequently MUSCULO-SKELETAL 61. Arthritis 62. Muscle Pain / Cramps 63. Painful Joints 64. Lameness 65. Backaches 66. Weakness No / Seldom / Frequently SKIN 67. Ulcerations 68. Itching 69. Rash No / Seldom / Frequently GASTROINTESTINAL 70. Indigestion 71. Abdominal Pain / Cramps 72. Constipation 73. Diarrhea 74. Blood in Bowel Movement 75. Black Bowal Movement 76. Increased Appetite 77. Increased Thirst 78. Decreased Appetite 79. Nausea and Vomiting 80. Difficulty Swallowing No / Seldom / Frequently MISCELLANEOUS 81. Fever 82. Chills 83. Night Sweats 84. Headaches 85. Insomnia 86. Nervousness 87. Irritability 88. Morning Tirdness 89. Easy Fatigability V. CHECK EACH ITEM - (if YES, state reason) YES NO 90. Have you ever been refused employment because of your health? 91. Have you ever been denied Life Insurance? 92. Have you ever been rejected for, or discharged from military service because of physical, mental, or other reasons? 93. Do you smoke? (if YES, what, how much per day, & for how long) VI. DO YOU HAVE, OR HAVE YOU RECENTLY HAD Yes No {when did it first appear, and how often} 94. Weight Loss: How Much? 95. Weight Gain: How Much? 96. Memory Defect 97. Change in Handwriting 98. Difficulty Walking in the Dark 99. Balance Problems 100. Numbness & Tingling in the Extremities 101. Hearing Loss 102. Ringing in the Ears 103. Change in Vision 104. Double Vision 105. Earaches 106. Running Ears 107. New Skin Growths 108. Changes in Skin Color 109. Tendency to Bleed or Bruse Easily 110. Athletes Foot 111. Intolerance to Heat 112. Intolerance to Cold 113. Change in Shoe or Hat Size 114. Lymph Node Enlargment 115. Kidney Stones 116. Gallbladder Stones VII. DO YOU HAVE ANY OTHER MEDICAL PROBLEMS WHICH ARE NOT MENTIONED ABOVE? 117. If so, Please Explain: VIII. IS THERE A FAMILY HISTORY OF ANY OF THE FOLLOWING: YES NO {If so, please indicate their relationship to you} 118. Tuberculosis 119. Diabetes 120. Cancer 121. Gout 122. Heart Problems 123. Strokes 124. High Blood Pressure 125. Asthma, Hay Fever, Hives 126. Glaucoma IX. What Medications (Pharmaceutical and/or Herbal) Are You Currently Using: 127. X. Have you been Hospitalized or Treated During the Past Year for ANY Significant Conditions? 128. If So, Please Indicate: XI. Are there ANY Other Health, Dietary or Family Matters that you would like to Discuss? 129. XII. Please List ANY Surgical Operations that you have had performed, include Your Age at the Time: 130.
XIII. If you did not have enough room to respond to a question, please use this space to add more data. Make sure to indicate the section & question numbers for each addition. 131.
Please make sure to look at the tongue in as natural light as possible.
2. Blimishes on Tongue Body: Are there any blisters, or other blemishes on the tongue body? Are there very small red or white speckles. If so, are they raised up from the durfice, or depressed into it?
3. Cracks on Body of Tongue: Does the body of the tongue show a lot of cracks, and/or is there a deep crack running down the center line. If so, where does the center crack start from & extend to? If there are many smaller cracks, where are they located?
4. Puffyness: Does the body look “puffy”, i.e. does it look overly large for your mouth; or is it very narrow, with a sharply pointed tip? If there is some puffyness, is it uniform on both sides of the tongue, or does it appear to be on only one side of the tongue? If so, which side is more pronounced?
5. Scalloping: If it is puffy, is there also a ripply, sort of wavy quality to the edges, or are they smooth;
6. Edge & Tip: Are the edges, and/or the tip a different shade than the body of the tongue? If so, what color are they?
7. Stability: Does the tongue shake when you stick it out to look at it? Does it have a fairly normal appearance, or does it have some type of covolution which you cannot make look "normal"? If so, can you describe what it looks like?
Coat: 8. Coat Color: What color is the coating, thick white, thin white, thin yellow, thick yellow, brown or black, or is there no noticeable coat at all?
9. Moisture: Does the coat look moist or dry, or does it perhaps have a very glossy almost mirrorlike quality?
10. Patches: Are there patches of areas where there is no coat, like holes in the coat, or perhaps just small areas of a coat, with most of the tongue having none?
11. Brushing: Do you brush your tongue when you brush your teeth?
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