History

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Name: _________________________________________________________

Date: ______________________

Health History:
Please indicate if you have ever been diagnosed with, treated for, or experienced symptoms of any of the following conditions:

Comments:
Kidney Disease___________________________
Angina/Chest Pain_________________________
Heart Attack/Heart Disease__________________
High/Low Blood Pressure___________________
Diabetes_________________________________
Shortness of Breath________________________
Asthma/Emphysema_______________________
Dizziness/Syncope_________________________
Seizures_________________________________
Bowel/Bladder Problems____________________
Rectal/Vaginal bleeding____________________
Osteoporosis_____________________________

Comments:
Cancer_________________________________
Rheumatic Fever_________________________
Tuberculosis/TB_________________________
Hepatitis________________________________
Stroke/TIA______________________________
Arthritis________________________________
Circulation Problems/Phlebitis______________
Muscle/Nerve Disorder____________________
Use Tobacco____________________________
(smoking/chewing)
Use Alcohol_____________________________
Are you pregnant? ________________________

Are you experiencing any of the following?


__ Unexplained cough of 2 weeks or more
__ Night Sweats
__ Unexplained fever
__ Unexplained weight loss
__ Loss of appetite
__ Bloody sputum
Please list any recent hospitalizations and/or surgeries along with approximate dates:

Please list the medications that you currently are taking:

Pain Log: Please shade areas that you are experiencing


pain and/or altered sensation. Is this pain and/or altered
sensation continual?
Yes________
No________

Pain Rating: Please circle one of the following


which best describes your pain today:
0

- No pain at all
- Very, very weak pain
- Very weak pain
Weak pain
3 Moderate pain
4 Somewhat strong pain
5 Strong pain
6
7 Very strong pain
8
9
10 Very, very strong pain
10+ - Maximal pain
.5
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2

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