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MEDICAL HISTORYPlease check the appropriate symptoms or conditions that you are experiencing nowGENERAL□ Allergies□ Weight loss□ Weight Gain□ Skin irritation□ Sweats□ Tremors□ Chills□ FeverNEUROLOGICAL□ Convulsions□ Dizziness□ Nausea□ Numbness□ Tingling/Burning□ Nervousness□ Depression□ Headaches□ Muscle weaknessMUSCLE & JOINT□ Shoulder□ Mid-back pain/stiffness□ Knee□ Hip□ Elbow□ Neck pain/stiffness□ Ankle/Foot□ Spinal curvature□ Hand/wrist□ Low-back pain/stiffnessGENITO-URINARY□ Kidney stones□ Urinary tract infections□ Painful urination□ Frequent urination□ Inability to control urinationGASTROINTESTINAL□ Gall bladder□ Liver trouble□ Vomiting blood□ Hernia□ Blood in stool□ Other__________________________________________RESPIRATORY□ Chest pain□ Difficulty breathing□ Spitting up blood□ Asthma□ Coughing□ Other__________________________________________CARDIOVASCULAR□ Hardening of arteries□ Poor circulation□ High blood pressure□ Cold extremities□ Swelling of ankles□ Other__________________________________________EYES, EARS, NOSE & THROAT□ Enlarged glands□ Deafness/Loss of hearing□ Enlarged thyroid□ Trouble speaking□ Difficulty swallowing□ Poor balance□ Blurred vision□ Other__________________________________________FOR WOMEN ONLY□ Hot flashes□ Irregular menstrual cycle□ Menopausal symptoms□ Lumps in breasts□ Other__________________________________________Are you pregnant?□ Yes□ NoIf yes, are you breastfeeding?□ Yes□ NoOTHER (specify any additional or unmentioned symptoms/conditions)____________________________________________________________________________________________________________________________________________________________333375178435Please circle any of the following conditions you presently have or have had in the pastALCOHOLISM EMPHYSEMA RHEUMATIC FEVER CANCER TUBERCULOSISPNEUMONIA ULCERS POLIO ANEMIA OTHER - specifySTROKE ARTERIOSCLEROSISGOUT EPILEPSY ________________HEART DISEASE OSTEOPOROSISARTHRITIS DIABETES ________________00Please circle any of the following conditions you presently have or have had in the pastALCOHOLISM EMPHYSEMA RHEUMATIC FEVER CANCER TUBERCULOSISPNEUMONIA ULCERS POLIO ANEMIA OTHER - specifySTROKE ARTERIOSCLEROSISGOUT EPILEPSY ________________HEART DISEASE OSTEOPOROSISARTHRITIS DIABETES ________________Signature_____________________________________________Date_________________ ................
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