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clinic provider
clinic provider
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Name of clinic provider:
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Patient name:
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DOB
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Date:
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Doctor
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HEALTH ISSUES AND CONDITIONS (Continued)
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Dizziness
Shoulder/Neck/Arm pain
Numbness in fingers
High Blood pressure
Difficulty Urinating
Weakness in Extremities
Breathing Problems
Fatigue
Lights Bother Eyes
Ears Ring
Broken Bones/Fractures
Rheumatoid Arthritis
Excessive Bleeding
Osteoarthritis
Pacemaker
Stroke
Ruptures
Eating Disorder
Drug Addiction
Gall Bladder Problems
Ulcers
Frequent Colds
Fever
Sinus Problems
Diabetes
Indigestion Problems
Joint Pain/Swelling
Menstrual Difficulties
Weight Loss/Gain
Depression
Loss of Memory
Buzzing in Ears
Circulation Problems
Seizures/Epilepsy
Low Blood Pressure
Osteoporosis
Heart Disease
Cancer
Coughing Blood
Alcoholism
Hiv Positive
Depression
SOCIAL HISTORY
Vigorous Exercise
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OFTEN
SOMETIMES
NEVER
Moderate Exercise
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OFTEN
SOMETIMES
NEVER
Alcohol Use
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OFTEN
SOMETIMES
NEVER
Drug Use
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OFTEN
SOMETIMES
NEVER
Tobacco Use
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OFTEN
SOMETIMES
NEVER
Caffeine
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OFTEN
SOMETIMES
NEVER
High Stress Activity
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OFTEN
SOMETIMES
NEVER
Family Pressures
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OFTEN
SOMETIMES
NEVER
Financial Pressures
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OFTEN
SOMETIMES
NEVER
Other Mental Stress
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Yes
No
Describe other mental stress:
*
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