Twitter Patient's First Name * Patient's Last Name * Email * Patient Date of Birth * General * Fever Weight Loss Decreased Appetite Excessive Fatigue None of These Check all that apply Eyes * Wearing Glasses Glaucoma Cataracts Infections Injuries None of These Check all that apply Date Of Last Eye Exam Ear, Nose, Throat & Mouth * Wearing Hearing Aids Nose Bleed Congestion Inability to Smell Sinus Sinus Headaches Sore Throat Mouth Sores Hoarseness Difficulty Swallowing None of These Check all that apply Date of last exam Cardiovascular * Chest Pain/Angina High Blood Pressure Irregular Pulse Heart Murmur High Cholesterol Swollen Hands/Feet Leg Pain While Walking Pacemaker None of These Check all that apply Date of last EKG Psychiatric * Depression Anxiety Mental Illness Sleeping Difficulty None of These Check all that apply Endocrine * Diabetes Thyroid Disease Hormone Problem Increased Thirst/Urination Increased Appetite None of These Check all that apply Respiration * Asthma Emphysema Bronchitis Chronic Cough Shortness of Breath Pneumonia Bloody Sputum Lung Cancer TB None of These Check all that apply Gastrointestinal * Persistent Nausea/Vomiting Blood in Vomit Heartburn Gallbladder Problems Hernia Abdominal Pain Ulcer/Gastritis Change in Bowel Habits Liver Disease Jaundice Diverticulitis IBS/Colitis Hemorrhoids Colon Cancer None of These Check all that apply Genitourinary * Urinary Tract Infection Painful Urination Blood in Urine Loss of Bladder Control Kidney Stones Sexually Transmitted Disease None of These Check all that apply Male Prostate Problems * Yes No Females * Menstrual Flow Irregular Menopause Uterine/Cervical Cancer Breast Pain Birth Control None of These Check all that apply Birth Control Method Date of last PAP Date of last mammogram Allergic/Immunologic * Food Allergies Inhalant Allergies None of These Check all that apply Hematology/Lymphatic * Anemia Bleeding Tendencies Phlebitis Persistent Swollen Glands/Lymph Nodes None of These Check all that apply Blood transfusion * Yes No Musculoskeletal * Back/Neck Pain Arm/Leg Pain Joint Pain/Swelling Arthritis Broken Bones Osteoporosis None of These Check all that apply Integumentary Skin disease/type * Yes No Rash * Yes No Neurological * Fainting/Blackout Spells Seizures Memory Problems Disorientation/Confused Concentration Problems Difficulty with Speech Double/Blurred Visions Facial Weakness Headaches Strokes Muscle Weakness Numbness/Tingling Tremors/Hand Shaking None of These Check all that apply Miscellaneous Eat salty foods * Yes No Add salt to your food * Yes No Eat out frequently * Yes No Drink coffee, tea, soda. * Yes No Drink alcoholic drinks. * Yes No Smoke cigarettes * Yes No Exercise regularly * Yes No Other medical problems Living will * Yes No Advanced Directive Power of Attorney * Yes No
