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MEDICAL HISTORY/ROSPatient Name: ______________________DOB: __________________Date: _____________Please check all prior and current medical problems: Cancer – Chemo therapy or radiation therapy Sleep Apnea Brain Aneurysm or Brain Hemorrhage Restless Leg Syndrome Stroke Chronic Back Pain Seizures Chronic Neck Pain Migraines Neuropathy Heart Attack High Blood Pressure High Cholesterol Irregular Heart Rhythm Thyroid Disorder Diabetes Other medical conditions: __________________ Anxiety/DepressionPlease indicate previous surgeries and date performed: Brain Surgery _________ Neck Surgery _______ Tonsil or Adenoids Removed _______ Back Surgery _______Other: _______________________________________________________________________Allergies: No known drug allergies______________________________________________________________________________Tobacco Use: Please any that apply: Cigarettes CigarsChewing TobaccoNumber/packs smoked in a day: _________Years of smoking: _______Quit: Yes / NoAlcohol Use: Yes / NoNumber of drinks/week: _________________Recreational Drugs: ___________________________________________________________Employment/Profession: ________________________________________________________Marital Status: Single Married Divorced Separated Widow Domestic PartnerChildren: ____________________________________________________________________Please list any medical problems of blood relatives:______________________________________________________________________________Patient Name: ______________________DOB: __________________Date: _____________Please check all prior and current medical problems:ConstitutionalGastro-intestinalNeurologic Weight Change Nausea/Vomiting Headache Loss of Appetite Fatigue Change in Bowel Habit Dizziness/ Vertigo Fever Bloody Stools FaintingChills Transient Loss of Responsiveness Night SweatsGenitourinary Difficulty with Speech Swollen Lymph Glands Frequency urinating Weakness Hesitation urinating NumbnessEyes Urgency Tingling Blurred/Loss of Vision Inability to Empty Bladder Convulsions Double Vision Tremors Light SensitivityMusculoskeletal Difficulty with Concentration Eye Pain Muscle Aches Memory Problems Joint PainsEar, Nose & Throat Muscle CrampsPsychiatric Altered hearing Neck / Back Pain Depressed Earache Hand/Arm/Leg/Foot Thoughts of Suicide Ringing Pain Anxiety Hoarseness Hallucinations Sore ThroatSkin Nasal Congestion RashesSleep Facial Pain Suspicious Lesions Snoring Change in Moles Stop Breathing in Sleep InsomniaCardiovascularEndocrine Restless Sleep or Frequent Chest Pain / Discomfort Heat Intolerance Awakenings Shortness of Breath Cold Intolerance Morning Headache Palpitations Excessive Thirst Nasal Congestion Excessive Hunger Daytime SleepinessRespiratoryImmunologic Cough Seasonal AllergiesOther: __________________ Shortness of Breath Hives or Rashes Wheezing Coughing up BloodReviewed by: ________________________ ................
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