Your Lifestyle                                                  
  Alcohol   Marijuana   Stress Regular Exercise Frequency    
  Tobacco   Drugs   Occupational Hazards Type       Frenquency    
Type      
General Symptoms                                              
  Poor appetite   Poor sleep   Bodily heaviness   Chills   Bleed or bruise easily
  Heavy appetite   Heavy sleep   Cold hands or feet   Night Sweats   Peculiar taste (describe)
  Strongly like cold drinks   Dream-distrubed sleep   Poor circulation   Sweat easily            
  Strongly like hot drinks   Fatigue   Shortness of breath   Muscle cramps            
  Recent weight loss/gain   Lack of strength   Fever   Vertigo or dizziness            
Respiratory                                                  
  Difficulty breathing   Tight chest   Cough Color of phlegm   Coughing blood
when lying down   Asthma/wheezing Wet or Dry?                 Pneumonia
  Shortness of breath (clear,white,yellow,green,etc)
Thick or thin?    
Cardiovascular                                                  
  High blood pressure   Low blood pressure   Chest Pain   Tachycardia   Coughing blood
  Blood clots   Fainting   Difficulty breathing   Heart palpitations   Pneumonia
Gastrointestinal                                                
  Nausea   Diarrhea   Intestinal pain or cramping Bowel movements:
  Vomiting   Constipation   Itchy anus
  Acid regurgitation   Laxative use   Burning anus Frequency   Texture/form    
  Gas   Black stools   Rectal pain       formed,loose, etc.
  Hiccup   Bloody stools   Hemorrhoid Color       Odor        
  Bloating   Mucous in stools (light,dark,black,etc) (esp. unusual)
  Bad breath
Musculoskeletal                                                
  Neck/shoulder pain   Upper back pain   Joint pain   Limited range of motion Other (describe)
  Muscle pain   Low back pain   Rib pain   Limited use          
Skin and Hair                                                  
  Rashes   Eczema   Dandruff   Change in hair/skin texture Other hair/skin problems
  Hives   Psoriasis   Itching   Fungal infections          
  Ulcerations   Acne   Hair Loss          
Neuropsychological                                              
  Seizures   Poor memory   Irritability   Considered/attempted Other (specify)
  Numbness   Depression   Easily stressed suicide            
  Tics   Anxiety   Abuse survivor   Seeing a therapist            
Genito-urinary                                                  
  Pain on urination   Blood in urine   Venereal disease   Increased libido   Impotence
  Frequent urination   Usable to hold urin   Bedwetting   Decreased libido   Premature ejaculation
  Urgent urination   Incomplete urination   Wake to urinate   Kidney stone   Nocturnal emission
Gynecology                                                  
Age menses began   Duration of flow   Vaginal discharge   Breast lumps Date of last PAP
                        # Pregnancies              
Length of cycle   Irregular periods   Vaginal sores # Live births  
(day 1 to day 1)   Painful periods   Vaginal odor Premature births   Date last period began
          PMS   Clots Age at Menopause _______            
Other