Name: ____________________________________________ Age ...



Name: ____________________________________________ Age __________ Date of Birth ______________

REVIEW OF SYMPTOMS: Have you noticed any of the following?

SYMPTOM YES NO COMMENTS

|Headache | | | |

|Dizziness/Fainting | | | |

|Visual problems, Double vision | | | |

|Temporary loss of vision (one or both eyes) | | | |

|Difficulty swallowing | | | |

|Stuffy nose/Sore throat/Earache | | | |

|Cough | | | |

|Have you coughed blood | | | |

|Skin rash | | | |

|Lumps | | | |

|Chest pain or pressure | | | |

|Shortness of breath | | | |

|Abdominal pains | | | |

|Nausea and vomiting | | | |

|Change in bowel habits/Bleeding/Black bowel movements | | | |

|Difficulty urinating/Blood in urine | | | |

|Do you get up at night to urinate? How often? | | | |

|Pain in joints | | | |

|Fever | | | |

|Weight loss or gain | | | |

|Pain in calf muscles or buttocks when walking | | | |

|Problems related to sexual dysfunction | | | |

|Vaginal discharge | | | |

|Are there problems of a personal nature that you would like to | | | |

|discuss with a doctor? | | | |

SOCIAL HISTORY

|Do you smoke? How much? | | | |

|Do you drink alcohol? How much? | | | |

|Do you use drugs? (marijuana, cocaine, crack, etc.) | | | |

|Have you ever engaged in any AIDS high risk activity? | | | |

|Do you wish to be tested for AIDS? | | | |

|Have you ever worked with chemicals, asbestos or other hazardous | | | |

|materials? | | | |

Physical, mental, and sexual abuse of children, spouses, etc. is a serious health and social problem. We can arrange for help for you if you let us know that you are in such a relationship.

Marital Status: _____________________________ Children: ______ Occupation: __________________________

Do you have a living will? _______________ Would you like information on one? ___________________________

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