|
Name______________________________________________________________________
Chills and fever:
Do you have chills and fever?____________________________________________________
When do they occur?___________________________________________________________
Check what applies:
1. Simultaneous chills and fever(_)
2. Chills predominant (_)
3. Fever predominant (_)
4. chills without fever (_)
5. fever without chills (_)
6. slight fever occurring at a definite time of day (_)
7. alternating chills and fever (_)
8. constant fever that rises during the evening (_)
9. Fever rises during the night (_)
10. irregular periods of low fever and lassitude(low energy) (_)
11. chills or cold limbs (_)
Perspiration:
Do you perspire? (_)
Perspire after heavy or slight exertion? (_)
Any odors with perspiration? (_)
Do you perspire at night? (_)
Do you perspire spontaneously/easily? (_)
Food and Drink/Appetite, Thirst and Taste:
How is your appetite? _________________________________________________________
Any changes recently?_________________________________________________________
Weight gain (_) or loss (_)?
How is you thirst?_____________________________________________________________
Prefer hot (_) or cold (_) drink?
Any food craving?_____________________________________________________________
Any feeling of fullness after a meal?_______________________________________________
If so, where?__________________________________________________________________
Any unusual tastes in your mouth?________________________________________________
Defication and Urination:
Do you get constipated (_) or have diarrhea (_)?
How many times a day do you urinate (______) have a bowel movement?(_____)
Is your urine scanty(_)or profuse(_)?
Is the color of urine clear(_), yellow(_), dark(_) or cloudy(_)?
Any pain or difficulty?__________________________________________________________
What is the consistency of your stools? Dry(_) soft(_) loose(_) wet(_)
Any undigested food (_), mucous(_)or blood(_) in the stool?
Pain(head/body, chest/abdomen, eyes/ears):
Where is your pain?____________________________________________________________
Is it fixed(_)or does it migrate(_)?
Is it relieved(_) or aggravated(_) by pressure?
Relieved by hot(_) or cold(_)?
Does it come and go?__________________________________________________________
Any Headaches?______________________________________________________________
Any specific time of day or night that it is worse or better?_____________________________
Sleep:
Do you sleep well?____________________________________________________________
How many hours?_____________________________________________________________
Do you have trouble staying asleep?_______________________________________________
Any trouble getting out of bed in the morning?_______________________________________
Any recurring dreams or nightmares?______________________________________________
Emotions:
What emotion do you tend to favor most? Circle one
: Fear(k) Anger(Lr) Joy(H) Sadness(Lu) Worry(S)
Check any ongoing Problems:
Hot hands/feet(_) cold hands/feet(_) Energy level good(_) poor(_) dizziness(_) Cravings(_) sorethroat(_)
dry throat(_) teeth problems(_) nose bleeds(_) sinus problems(_) Headaches(_) bleed or bruise easily(_)
Digestive(_) hemorrhoids(_) bloody stools(_), black stools(_) gas(_) bloating(_) Pain(_) where?_________
Bad breath(_) belching(_) ulcers(_)
Cardiovascular: HBP(_) LBP(_) Chest Pain(_) Irregular heartbeat(_) blood clots(_) fainting(_)
difficulty breathing(_) swelling of hands/feet(_)
Respiratory: cough(_) coughing blood(_) trouble breathing(_) asthma(_) short of breath(_)
Genito-urinary: pain on urination(_) Frequent urination(_) Blood in urine(_) urgency to urinate(_)
Unable to hold urine(_) kidney stones(_) venereal disease(_) impotency(_)
How often at night? (___)
Musculoskeletal: Neck pain(_) muscle pain(_) back pain(_) joint pain(_)
Other joint or bone problems:______________________________________________________
Neurosychological:seizures(_) areas of numbness(_) Poor memory(_) concussion(_) Depression(_)
anxiety(_) bad temper(_) easily stressed(_) treated for emotional or psychological problems?(_)
Habits: cigarettes(_) coffee(_) tea(_) alcohol(_) drugs(_) sugar(_) salt(_) other(_____________)
Menses and Leukorrhea(Females Only):
Number of pregnancies(_) # of births(_)
Is your period the same time each month?___________________________________________
How far apart is your cycle? (time between periods)__________________________________
Is your flow heavy(_) or light(_)?
What color is it?_______________________________________________________________
Any clots? (_) Pain?(_)
Do you have or have you had vaginal discharge? (_)
What is the consistency, color and odor?____________________________________________
|
