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|SYMPTOM |YES |NO |NOT SURE |SYMPTOM |YES |NO |NOT SURE |

|Alcohol problems | | | |Muscle tension/cramps | | | |

|*Allergies To Medications | | | |Nausea | | | |

|Anger | | | |Nervousness | | | |

|Asthma | | | |Neurological disease | | | |

|Back pain | | | |Numbness | | | |

|Blackouts | | | |OB/GYN disorder | | | |

|Cancer | | | |Overweight | | | |

|Chest pains | | | |Pounding heart | | | |

|Chronic cough | | | |Paralysis | | | |

|Chronic pain | | | |Pessimistic attitude | | | |

|Clenching/tightness of jaw | | | |Physical trauma | | | |

|Cold hands/feet | | | |Prostate problems | | | |

|Colds/Flu | | | |Rapid heart beat | | | |

|Colitis | | | |Recent weight gain | | | |

|Constipation | | | |Recent weight loss | | | |

|Decreased productivity | | | |See things others don’t | | | |

|Diabetes | | | |Sexual difficulties | | | |

|Diarrhea | | | |Sexually transmitted diseases | | | |

|Difficulty falling asleep | | | |Shortness of breath | | | |

|Difficulty staying asleep | | | |Sinus congestion | | | |

|Dizziness/fainting | | | |Skin problems | | | |

|Don’t like being touched | | | |Social withdrawal | | | |

|Drug abuse/dependence | | | |Stomach trouble | | | |

|Dry Mouth | | | |Stroke | | | |

|Epilepsy or seizures | | | |Sugar/albumen in urine | | | |

|Excessive sweating | | | |Suicidal thoughts | | | |

|Exhaustion | | | |Suicide attempts | | | |

|Eye trouble | | | |Tearful/crying spells | | | |

|Fatigue | | | |Thyroid disease | | | |

|Feelings of inadequacy/Loss of | | | |Thyroid trouble | | | |

|self esteem | | | | | | | |

|Flushes | | | |Tics | | | |

|Gastrointestinal disease | | | |Tingling | | | |

|Glaucoma | | | |Tremors | | | |

|Grinding of teeth | | | |Twitches | | | |

|Head Injury/Loss of consciousness| | | |Ulcers | | | |

|Hear things others don’t | | | |Unable to relax | | | |

|Hearing problems | | | |Underweight | | | |

|Heart attack/heart trouble | | | |Visual disturbances | | | |

|High blood pressure | | | |Vomiting | | | |

|Indigestion | | | |Watery eyes | | | |

|Infectious disease | | | |Other conditions: | | | |

|Jaundice/liver disease | | | |Allergies to Medication: | | | |

|Kidney disease | | | |Date of Most Recent Labs and | | | |

| | | | |What Tests: | | | |

|Loss of appetite | | | |Take Herbs: | | | |

|Loss of interest or enjoyment in | | | |Date of Last Menstrual | | | |

|activities | | | |Period: | | | |

|Low blood pressure | | | |Height: | | | |

| | | | |Weight: | | | |

*Please list all medication allergies here: _____________________________________________________

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