ENVIRONMENTAL HISTORY SYSTEMS REVIEW FORM NAME DATE

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Transcription:

ENVIRONMENTAL HISTORY SYSTEMS REVIEW FORM NAME DATE Please complete the following. Number the items with a 1 for MILD, 2 for MODERATE, and 3 for SEVERE. Leave the line blank if it does not apply to you. SKIN Abnormal pigmentation, brown spots Acne Change in a mole Dry/scaly skin Easy bruising Frequent itching EYES Bags/dark circles Blurred vision Cataract/glaucoma Swollen, red, sticky eyelids Watery, itchy eyes Other eye diseases/injury Flushing/hot flashes Hair loss Frequent infections/boils Hives, rash, eczema Oily skin Skin cancer Skin disease EARS Drainage from ear Earaches, infections Itchy ears Hearing loss Ringing in the ears

NOSE Frequent stuffy/runny nose Frequent colds Hay fever Nose bleeds Sneezing attacks Sinus Problems CIRCULATORY Pulsations in abdomen Abnormal exam/test Chest pain/tightness Cold hands/feet Color changes in toes/feet Difficulty walking 1-2 blocks Discoloration/sores of feet MOUTH/THROAT Bleeding gums Canker sores Chronic coughing Dry mouth Gagging, clearing the throat Lump in the throat Sore throat Hoarseness/loss of voice Sore tongue Swollen/discolored tongue/lips Heart murmur Mitral valve prolapse Heart attack/heart disease High cholesterol/triglycerides High/Low Blood Pressure Leg cramps at rest or night Palpitations Rapid/Skipped Heartbeats Stroke Swelling of hands/feet/ankle Varicose veins/phlebitis

RESPIRATORY Asthma/Chronic Bronchitis/Emphysema Chest congestion/frequent Cough Coughing up blood Frequent exposure to chemicals/dust/etc. Pleurisy/Pneumonia/Tuberculosis Shortness of breath/difficulty breathing Smoking Sputum Wheezing Any other lung trouble DIGESTIVE Appetite (poor, medium, good) Belching/passing gas Bleeding/Black stools Bloated feeling Colitis/Diverticulitis/Polyps Hemorrhoids Hepatitis/Liver trouble Jaundice Mucous in stool Nausea/Vomiting Constipation/Painful bowel movements Diarrhea Peptic ulcer Gallbladder disease Heartburn/Indigestion

KIDNEY/BLADDER Blood/Sugar/Pus in urine Burning/Painful urination Frequent urinating Night time urination Gravel/stone in urine Kidney/Bladder infection Kidney/Bladder disease Water retention Weak bladder JOINTS/MUSCLES Swelling/pains/aches in joints Arthritis Back/Neck pains Bursitis Difficulty in walking Gout Gout Pain/aches in muscles Spasms/cramps in muscles Rheumatism Sciatica Tremors of hands/feet Pain/aches/cramps/spasms in muscles Rheumatism

NEUROLOGICAL Back pains Convulsions Epilepsy Fainting spells Frequent headaches ENDOCRINE Heat/Cold intolerance Diabetes Steroid prescriptions in past Excessive thirst Excessive appetite Head injury/concussion Loss of coordination Memory Problems Migraine headaches Multiple Sclerosis Muscle twitchings Nervous Disease HEMATOLOGICAL Abnormal bleeding Anemia (past, present) Blood disease Cuts/Bruises slow to heal Phlebitis/Thrombosis Neuritis Paralysis Radiating pain down the legs Tingling/Numbness of arms, legs, face Weakness of arms, legs, or face

GENERAL Excessive fatigue Frequent anger/irritability Frequent nightmares Frequent crying spells Frequent depressed spells Frequent illness Frequent loneliness Frequent suicidal thoughts MIND Confusion Difficulty making decisions Irritability Learning disabilities Poor concentration Poor memory Slurred speech Stuttering/stammering General weakness/tires easily Insomnia/sleep related issues Loss of ambition Mood swings Nervous breakdown Poor general health Stressful job/life WEIGHT Binge eating/drinking Compulsive eating Craving certain foods Water retention Over/Underweight Unusual fears Unusual Stress/Anxiety Reduced sex drive Other sexual problems ENERGY Lethargy/Apathy Hyperactivity

MALES Discharge from penis Painful/swollen testicles Prostate trouble Trouble with ejaculation Trouble with erection Sexually transmitted disease Date of last prostate exam FEMALES Irregular/painful menses Bleeding between periods Cysts/Tumors of Ovary/Uterus Sex drive reduced/lacking Pain during intercourse Vaginal dryness Vaginal infections/itching/discharge Hair growth on face or body Hot flashes/mood swings/depression Date of last menstrual period Date of last mammogram Date of last PAP smear

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