Name	Address
City, State	Zip Code
Phone	E-mail
Birthday (07/31/1968)	Sex (male or female)
Occupation	Employer
Employment Status school keeping house work full time part time unemployed disabled retired
Referred By	Married, Children (yes, 2)
Give the following information for the last times you have been hospitalized starting with the most recent (except normal prganancies): include type of illness, month and year hospitalized, name of hospital, city and state. #1 #2 #3
Allergies	Medications
Medicinal Herbs, Vitamins, Teas
Do you use : Coffee, Cigarettes or Alcohol Coffee Amount Cigarette Amount Alcohol Amount
Year - Tests Chest X Ray Electrocardiogram TB Test GI Series Kidney X Ray Barium Enema Other X Rays	Year - Immunizations Smallpox Tetanus Polio Typhoid Mumps/Measles Flu Other
If you've been bothered recently by any of these problems please check the box. Questions should be answered Left to Right.
Frequent / Severe Headaches Loss of Balance Blackouts / Fainting Blurry Vision See Double Eye Pains or Itching Earaches Running Ears Dental Problems Sore Tongue Running Nose Head Colds Sore Throat Hoarse Voice Frequent Coughing Chest Colds Chest Pains Frequent Belching Vomiting Bloated Abdomen Loose Bowels Grey or Whitish Stools Itching Rectum Frequent Urination Burning on Urination Weak Urine Stream Constant Urge to Urine Swollen Joints Weakness in Arms / Legs Trembling Leg Cramps Scalp Problems Bruise Easily Nervous with Strangers Difficulty Making Decisions Loss of Memory Frequent Crying Difficulty Relaxing Scary Dreams Shy Angered Easily Family Problems Sexual Difficulties	Neck Lumps or Swelling Dizzy Spells Wear Glasses Eyesight Worsening See Haolos or lights Watering Eyes Hearing Difficulties Noises in Ears Sore or Bleeding Gums Congested Nose Sneezing Spells Nose Bleeds Difficulty Swallowing Wheezing or Gasping Cough Up Phlegm Rapid or Skipped Heart Beats Recurring Indigestion Nausea Pain in Abdomen Constipation Black Stools Pain in Rectum Blood with Stools Involuntary Urination Black or Bloody Urine Difficulty Starting to Urine Aching Muscles / Joints Back or Shoulder Pains Painful Feet Numbness Skin Problems Burning Skin Nervousness or Anxiety Nail Biting Lack of Concentration Lonely or Depressed Hopeless Outlook Worry A Lot Feeling of Desperation Dislike Criticism Annoyed by Little Things Problems at Work Change of Sexual Energy
Women Only
Missed Period Bleeding Between Periods Bearing Down Feeling Genital Irritation	Menstrual Problems Heavy Bleeding Vaginal Discharge Swelling of Breast
Men Only
Burning or Discharge Painful Testicles	Swelling of Testicles

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