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~, ., PATIENT SYMPTOM SURVEY DATE____________ PATIENT'S NAME___________________________AGE____ WEIGHT _____ HEIGHT _____ BODY FAT % _____ BLOOD PRESSURE ________ PULSE_____ This is a confidential patient symptom survey. Please check each condition which is true for you. If the condition does not apply to you or you do not understand a term or if you are not sure if a condition applies to you, then do not check the box. Use common sense. For example, Insomnia once in the last month probably isn't that important and would not be marked. However, Insomnia occurring -2 times per week is notable and would be marked. Please take your time... Remember to hydrate well before the exam. Primary Complaints 090 091 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 035 036 037 038 039 040 041 042 043 General Good Health Desires Nutritional & Metabolic Analysis Skin Disorder Acne Psoriasis Urticaria (Hives) ADD/ADHD Allergies Food Allergy Sinusitis Alzheimer's Poor Concentration/Memory Parkinson's Disease Anemia Arthritic Disorder Osteoporosis Asthma Emphysema Chronic Fatigue Circulatory Disorder Heart Disease High Cholesterol High Blood Pressure Low Blood Pressure Tachycardia (High Heart Rate) Numbness Constipation 044 Indigestion 045 D Ulcerative Colitis 046 Depression 047 Diabetes Mellitus 048 Hypoglycemia 049 Dizziness/Balance Problem. 050 Ear Infection 051 Epstein Barr 052 Eye Problems 053 Cataracts 054 Glaucoma 055 Macular Degeneration 056 Fever 057 Fibromyalgia 058 Gallbladder Disorder 059 Gout 060 Headaches 061 Hearing Loss 062 Infertility, male 063 Prostate Disorder 064 Liver Disease 065 Hepatitis 066 Hepatitis B 067 Hepatitis C 068 Kidney/Bladder Problems 069 Hyperthyroid 070 Hypothyroid 071 Lupus 072 Infertility, female 073 Interstitial Cystitis 074 075 076 077 078 079 080 081 082 083 084 085 086 087 017 Irregular Menstrual Cycle Menopausal Symptoms Hot Flashes Mental Disorder Insomnia Mouth/Throat/Tongue Canker Sores Overweight Underweight Sexual Disorder Spinal Problems Obesity GERD HIV infection Cancer 018 Breast 019 Prostate 020 Lung 021 Colon/Rectal 022 Skin 023 Leukemia 024 Lymphoma 025 Brain Tumor 026 Other 088 089 Crohn's Disease Irritable Bowel Syndrome Please state your most significant concern(s):______________________________________________ 1 General Health 100 Base of fingernails are pink 101 Base of fingernails are purple Fingernails have 102 ridges or white spots 103 Fingernails are soft 104 Fingernails are splitting 105 Fingernails peel 106 Pale fingernail beds 107 Black out easily 108 Balance problems 109 Difficulty walking 110 Have tattoos 111 Brittle hair 112 Dry hair 113 114 115 Thin hair Hair loss Drink alcoholic beverages daily Drink less than 8 glasses of water a day Currently on Chemotherapy Currently on radiation treatment Had chemotherapy in the past Had radiation treatments in the past Gained over 20 Ibs in the last 12 months Somewhat Overweight Somewhat Underweight 116 117 118 119 120 121 122 123 124 Unexplained weight loss of over 20lbs within the last 4 months 125 Energy level is worse than it was 5 years ago 127 Sleep less than 6 hours per night 128 Unable to recall dreams the next day 129 Sensitive to chemicals, paint, fumes, cologne 130 Had blood transfusion in the past 131 Had transplant in the past 132 Had a major accident or injury (i.e. auto, work,other) Lifestyle Habits 370 371 372 373 374 375 376 377 700 701 702 703 715 Drins alcohol Drink caffeinated coffee Drink caffeinated pop/soda Drink caffeinated tea Drink decaffeinated coffee Drink decaffeinated Pop/soda Drink decaffeinated tea Drink more than 3 cups of coffee per day Tonsillectomy and/or Adenoids Appendix Gallbladder Thyroid Radiated thyroid 378 379 388 380 381 382 383 708 704 705 706 707 Drink more than 3 cups of tea per day Drink 1 or more pop/sodas per day Drink diet pop/soda Drink beverages from a can Have more than 5 alcoholic drinks per week Currently smoke Quit smoking in the last 5 years 384 385 126 133 386 134 135 136 387 Smoked for more than 5years Smoke more than 1 pack per day Rarely exercises Regularly exercises Take Vitamins Vegetarian Eat no red meat Eat no meat, no dairy Frequent use of artificial sweeteners Surgeries Cancer Hysterectomy, complete Hysterectomy, partial Tubal ligation Breast implants 709 Coronary bypass 710 Spinal surgery 711 Extremity surgery 71 2 Hip replacement 713 Knee replacement 2 265 266 267 268 269 270 271 272 273 274 275 276 4-5 bowel movements per week 3 or fewer bowel movements per week 6 or more bowel movements per week Black tarry stools Pale or yellow colored stool Blood stools Constipation Hemorrhoids Loose bowel movements Frequent diarrhea Frequent nausea Frequent vomiting 485 486 487 488 489 490 Catch severe colds Chronic chest condition Chronic cough Constant runny nose COPD Difficulty breathing 400 401 Bad breath Bitter taste in the mouth in the morning Dry mouth Excessive saliva Sores or cracks in the corners of the mouth Glands often swell Frequent canker sores 402 403 404 405 406 245 246 247 248 Gastrointestinal 277 Abdominal gas 278 Belching and burping after eating 279 Bloated after eating 280 Severe abdominal pains 281 Stomach ulcers 282 Uses digestive aids 283 Uses laxatives 284 Immediate indigestion upon eating 285 Indigestion in 2 hours or more after meals 286 Indigestion within 1 hour after meals 287 Difficulty swallowing Coarse hair Coarse skin Diabetic Excessive thirst 491 492 493 494 495 496 407 408 409 410 411 412 413 414 249 250 251 252 289 Eat when nervous 290 Excessive hunger 291 Poor appetite 292 Experiences fainting spells when hungry 293 Feels shaky when hungry 294 Frequently drowsy after eating a meal 295 Gall bladder disease 296 Has had intestinal worms 297 Reflux/Hiatal hernia 298 Liver disease 299 Irritable Bowel Syndrome 288 Eating relieves fatigue Respiratory Frequent colds Frequent nose bleeds Frequent sinus infections Frequent stuffy nose Hay fever Nasal polyps Mouth and Throat Frequent fever blisters Frequent sore throats Frequently has a sore tongue Sore gums Swollen gums Swollen tongue Tongue burns Tongue has grooves or fissures Endocrine Frequently feel cold Frequently feel hot Get lightheaded when standing quickly Heals slowly 497 498 499 500 501 502 415 416 417 418 420 419 253 254 Night sweats Post nasal drip Sneezing spells Spit up blood Spits up phlegm Wheezes Tongue is coated Gums bleed when brushing teeth Toothaches Amalgam dental fillings Other dental fillings (gold, composite, etc) Has had root canal(s) Unusually jumpy or nervous Unusually tired most of the time 3 190 Cold Feet 191 Cold hands 192 Experience Cardiovascular 200 Pain in the heart or chest 195 Leg cramps during 201 Spells of rapid heart rate bedtime 202 Troubled with blood clots 196 Leg cramps during 203 Unusually slow pulse rate daytime 204 Varicose veins 197 Low blood pressure 530 Skin is rough, especially shortness of breath while sitting still 193 Heart skips beats 194 Tendency of High blood at times 198 Pain in lep/hips when 199 Frequent swollen ankles Pressure walking Skin on the back of the arms 520 Bruise easily 526 521 Excessive perspiration 527 Problems with Eczema 531 Skin is tender 522 Frequent goose bumps 528 Has moles which are 532 Sores that heal slowly 523 Has acne changing in size and/or 533 Troubled with boils 524 Has Psoriasis color 534 Dry skin 525 Hives 224 Ringing or noises in the 529 Itchy skin Skin eruptions Ears 220 Discharge from ears 222 Punctured ear drum 221 Hard of hearing 223 Recurrent ear infection ears Eyes 320 Bloodshot eyes 325 Eyes watery 321 Blurred vision 326 Mild Glaucoma 322 Cross eyes 327 Far Sighted 330 Itchy eyes 323 Eye pain 328 Developing cataracts 331 Near sighted 324 Eyes feel gritty 332 Dry Eyes 329 Mild Macular degeneration Feet 350 Corns 351 Frequent foot crmps 352 Heel spurs 353 Painful feet 355 Swelling in the feet/ankles 354 Plantar warts 356 Plantar fascitis 357 Fungal infection Neuromuscular 459 Pain between the 450 Has Osteoarthritis shoulders 451 Has Rheumatism 460 Shoulder/arm pain 461 Numbness/tingling in the 440 Bites nails 441 Frequent muscle soreness 452 Rheumatoid Arthritis 442 Muscle spasms 453 Joint stiffness in the morning 443 Muscle weakness 454 Swollen joints 462 Sleep walks 444 Tremors 455 Leg pain at rest 463 Stutters or stammers 445 Frequent headaches 456 Spinal curvature 464 Nerve pain 446 Often Dizzy 457 Low back pain 447 Frequently feels faint 458 Neck pain 448 Has Epilepsy 449 Has motion sickness body 4 150 151 152 153 154 155 156 157 555 556 557 558 Afraid to eat anywhere except home Always needs someone to advise Cry often Difficulty concentrating Difficulty falling asleep Difficulty staying asleep Easily angered Feelings are easily hurt 158 Urinate more than 2 times per night Bed wetting Blood in the urine Difficulty starting urination 559 560 561 562 585 Difficulty completing intercourse 586 Difficulty getting or keeping an erection 587 Discharge from the urethra 610 611 612 613 614 615 616 617 618 Heavy hair growth on face or body Cycles are every 27-29 days Abnormal cycle >29 days and/or <26 days PMS Menstrual cramps Painful periods Acne worse at menstruation Excessive menstrual flow Retains fluid during period s 159 160 161 162 163 164 165 563 Behavior Problems Frequently becomes scared for no reason Frequently miserable or blue Have to be on guard even with friends Often annoyed by people Recurrent bad dreams Sometimes wishes to be dead or away from it all Upset by criticism Poor memory 166 167 Scared to be alone Strange people or places cause fear 168 Under considerable emotional stress 169 Unhappy when other are happy 170 Brain fog Urinary Painful urination 564 Frequent urination. Troubled by urgent urination 565 Incontinence when sneezing or laughing 566 Loses bladder control 588 589 590 591 592 619 620 621 622 623 624 625 Frequent bladder infections Frequent kidney infections Kidney stones Men Only Had a vasectomy Had difficulty fathering children Lumps in the testicles Painful genitals Prostate troubles 593 594 595 Sores on external genitalia Herpes Sexual diseases Women Only Pre-menstrual depression Currently taking birth control medication Has taken birth control medication more than 1 year s taken birth control medication within the last year Has had miscarriage Hot flashes Takes hormone replacement medication 627 628 629 630 631 633 634 635 636 637 638 Diminished sexual desire Painful intercourse Poor or infrequent orgasm Lumps in the breasts Tender breasts Vaginal discharge Bloody spotting discharge Yeast infections Sores on external genitalia Herpes Sexual diseases 5 Medications Please list all drugs you are currently taking including over the counter drugs, aspirin, etc. Also, list how long you have taken each drug and the condition for which it was prescribed. DRUG _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ PRESCRIBED FOR: ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ HOW LONG ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Please list all drugs taken within the last year including over the counter drugs, antibiotics, aspirin, inhalers, etc. Also, list how long you have taken each drug and the condition for which it was prescribed. DRUG _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ PRESCRIBED FOR: ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ HOW LONG ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ Please list all vitamins/herbs/supplements you are currently taking. Also, list how much of each supplement you are taking. VITAMIN/HERB _____________ _____________ _____________ _____________ _____________ _____________ FOR WHAT: ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ HOW LONG ___________ ___________ ___________ ___________ ___________ ___________ Please list all tattoos you have (Location, Date, Sterile/Not, Infection, Hepatitis Testing) _____________ _____________ ____________________________ ____________________________ ___________ ___________ 6 FOOD DIARY Please list what you have eaten and drank over the past week. Include all snacks and beverages (alcohol, coffee, tea, etc.). Try to remember portion sizes. Don’t fret too much, do the best you can. _____DAY Breakfast_____________________________________________________________________ Snack___________________________________ Lunch________________________________________________________________________ Snack___________________________________ Dinner________________________________________________________________________ Snack___________________________________ _____DAY Breakfast_____________________________________________________________________ Snack___________________________________ Lunch________________________________________________________________________ Snack___________________________________ Dinner________________________________________________________________________ Snack___________________________________ _____DAY Breakfast_____________________________________________________________________ Snack___________________________________ Lunch________________________________________________________________________ Snack___________________________________ Dinner________________________________________________________________________ Snack___________________________________ _____DAY Breakfast_____________________________________________________________________ Snack___________________________________ Lunch________________________________________________________________________ Snack___________________________________ Dinner________________________________________________________________________ Snack___________________________________ _____DAY Breakfast_____________________________________________________________________ Snack___________________________________ Lunch________________________________________________________________________ Snack___________________________________ Dinner________________________________________________________________________ Snack___________________________________ _____DAY Breakfast_____________________________________________________________________ Snack___________________________________ Lunch________________________________________________________________________ Snack___________________________________ Dinner________________________________________________________________________ Snack___________________________________ _____DAY Breakfast_____________________________________________________________________ Snack___________________________________ Lunch________________________________________________________________________ Snack___________________________________ Dinner________________________________________________________________________ Snack___________________________________ 7
