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Date of Birth

Constitutional
fever, heat stroke, weight loss, weight gain, unusually tired, etc.
Ear/Nose/Throat
hard of hearing, stuffy nose, earache, cough, dry mouth, etc.
Heart (Cardiovascular)
high blood pressure, racing pulse, chest pain, unable to exercise, etc.
Lungs (Respiratory)
congestion, wheezing, shortness of breath, productive or bloody cough, asthma, etc.
Digestion (Gastrointestinal)
stomach upset, diarrhea, constipation, hernia, ulcers, pain/cramps, acid reflux, etc.
Muscles and bones (Musculoskeletal)
muscle pain/cramps, joint pain swelling, stiffness, etc.
Urological
painful or frequent urination, burning, impotence, incontinence, infections, etc.
Gynecological
pregnancies, menstrual problems, ovarian and uterine conditions, etc.
Breast
cysts, fibroids, pain, numbness, lumps, etc.
Neurological
numbness, weakness, headaches, paralysis, seizures, tremors, tingling, etc.
Psychiatric
depression, anxiety, mood swings, insomnia, hallucinations, disorientation, etc.
Blood/Lymphatic
high cholesterol, anemia, blood disorders, leukemia, prolonged bleeding, etc.
Skin
itching, rash, infection, ulcer, tumors or growths, warts, excessive dryness, etc.
Cancer
fever, heat stroke, weight loss, weight gain, unusually tired, etc.
Allergic/Immunologic
recurrent infections, hay fever, food allergy, drug sensitivity, hives, redness, itching, etc.
Hormones (Endocrine)
diabetes, thyroid problems, fatigue, hair loss, hot/cold intolerance, etc.
Major illnesses/hospitalizations
Surgeries
If diabetic: Year of diagnosis

Systemic Disease

Have you been exposed to venereal disease/sexually transmitted infection?
Are you pregnant
Occupational exposure
Recent travel
Tobacco use
Alcohol use
Recreational drug use

Medications: List ALL medications you are CURRENTLY taking. (Include all herbals, vitamins and supplements)

Name
Dose
Frequency
Other information

Allergies: Please list ALL allergies

Allergy
Severity
Reaction
Treatment information

Signature
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