Name:(Required) Appointment Date:(Required) MM slash DD slash YYYY RespiratoryAsthma Yes No Emphysema/COPD Yes No Recent or current smoker Yes No Shortness of breath – exertion Yes No Shortness of breath – lying flat Yes No Persistent cough Yes No Cardiovascular High cholesterol Yes No Congestive heart failure Yes No Swollen extremities Yes No History of stroke/TIA Yes No Sensation of rapid heartbeat Yes No Sensation of slow heartbeat Yes No History of heart attack Yes No Chest pain/discomfort Yes No Diagnosis with POTS Yes No ConstitutionalWeight gain Yes No Weight loss Yes No Obesity Yes No Problem losing weight Yes No Problem gaining weight Yes No EndocrineExcessive sweating during day Yes No Excessive sweating at night Yes No Itching of hands or feet Yes No Low thyroid Yes No High blood pressure Yes No Diabetes Yes No Low blood pressure Yes No GastrointestinalBloating after meals Yes No Diarrhea Yes No Loss of appetite Yes No Excessive thirst Yes No Increased appetite Yes No Constipation Yes No Heartburn Yes No Nausea/Vomiting Yes No Difficultly swallowing/choked Yes No Saliva dropped out of mouth Yes No Diagnosis with Gastroparesis Yes No Abdominal Pain Yes No HematologicAnemic Yes No Bleeding while brushing teeth Yes No On blood thinners Yes No Nosebleeds Yes No Bruising Yes No Pro-longed bleeding Yes No MusculoskeletalPain in legs Yes No Poor leg circulation Yes No Arthritis Yes No Leg cramps Yes No Muscle weakness/aches Yes No Diagnosis with EDS Yes No NeurologicFainted in the last 6 months Yes No Dizziness/lightheadedness Yes No Lightheadedness with standing Yes No Confusion/Impaired memory Yes No Impaired memory on standing Yes No Slurred speech Yes No Feeling of vertigo Yes No Headache/head pounding Yes No Seizures Yes No Tremors Yes No Trouble tolerating cold Yes No Trouble tolerating heat Yes No OphthalmologicCataracts/Glaucoma Yes No Sensitive to light Yes No Seeing double Yes No Blurry vision Yes No Blurry vision with standing Yes No PsychologyDepression Yes No Irritability/impatient Yes No Sleep apnea Yes No Snoring Yes No Trouble concentrating Yes No Currently using a CPAP/BiPAP Yes No Fatigue/feeling weak Yes No Anxiety Yes No Always tired during the day Yes No Falls asleep during inappropriate times Yes No Frequent wakening at night Yes No Overall restless sleep Yes No Difficultly maintaining sleep Yes No Stop breathing at night Yes No UrologicDifficult starting to urinate Yes No Frequent urination Yes No Urinary leaking Yes No Δ
