ࡱ>   Jbjbj #ccA` ` !t#1##"$$$%%%1 1 1 1 1 1 1$3;6D1(h%"%((D1$$KY1,,,(8$$1,(1,,..$ 87). 1o101.6*H6..&6/%&^,l&L&%%%D1D1a+*%%%1((((6%%%%%%%%%` m:  PATIENT SYMPTOM SURVEY DATE_________________ PATIENTS NAME_______________________________________ AGE_______ WEIGHT_________ HEIGHT_________ BLOOD PRESSURE___________ PULSE___________ O2__________ This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box. Use common sense. For example, Insomnia once last month probably isnt that important and would not be marked. However, Insomnia 1-2 times per week is notable and would be marked. Please take your time Primary Complaints 090 ( General Good Health 091 ( Desires Nutritional & Metabolic Analysis 001 ( Skin Disorder L25.9 002 ( Acne L70.8 003 ( Psoriasis L40.8 004 ( Urticaria (Hives) L50.9 005 ( ADD/ADHD F90.1/F90.9 006 ( Allergies, Unspecified J30.9 007 ( Allergic Rhinitis from food J30.5 008 ( Sinusitis J01.90 009 ( Alzheimers G30.9 010 ( Poor Concentration/Memory F07.8 011 ( Parkinsons Disease G20 012 ( Anemia D64.9 013 ( Arthritic Disorder M12.9 014 ( Osteoporosis M81.0 015 ( Asthma J45.909 016 ( Emphysema J43.9 017 ( Cancer 018 (Breast C50.919female C50.929male 019 (Prostate C61 020 (Lung C34.90 021 (Colon and Rectal C18.9 022 (Skin C44.90 023 (Leukemia w/o remission C95.90 Leukemia w/ remission C95.91 024 (Lymphoma, malignant C85.89 025 (Brain Tumor, malignant C71.9 027 ( Anxiety Disorder F41.9 028 ( Autism F84.0 033 ( Edema R60.9 034 ( Eczema L25.9 035 ( Chronic Fatigue R53.82 036 ( Circulatory Disorder I99.9 037 ( Heart Disease I51.9 038 ( High Cholesterol E78.0 039 ( High Blood Pressure I10 040 ( Low Blood Pressure I95.9 041 ( Tachycardia (High Heart Rate) R00.0 042 ( Numbness R20.9 043 ( Constipation K59.00 044 ( Indigestion K30 045 ( Ulcerative Colitis K51.90 046 ( Depression F32.9 047 ( Diabetes Mellitus E11.9 030 ( Diabetes Type I E10.9 031 ( Diabetes Type II E11.65 029 ( Hyperglycemia [high blood sugar] R73.09 048 ( Hypoglycemia [low blood sugar] E16.2 049 ( Dizziness/Balance Problem R42 050 ( Ear Infection H65.90 051 ( Epstein Barr B27.90 052 ( Eye Problems H57.13 053 (Cataracts H26.9 054 (Glaucoma H40.9 055 (Macular Degeneration H35.30 056 ( Fever R50.9 057 ( Fibromyalgia M79.7 058 ( Gallbladder Disorder K82.9 059 ( Gout M10.9 060 ( Headaches R51 061 ( Hearing Loss H91.90 062 ( Infertility, male N46.9 064 ( Liver Disease K76.9 065 (Hepatitis K71.6 066 (Hepatitis B B16.9 067 (Hepatitis C B17.10 068 ( Kidney Disorder N28.9 or Bladder Disorder N32.9 063 ( Prostate Disorder N42.9 069 ( Hyperthyroidism E05.90 070 ( Hypothyroidism E03.9 071 ( Systemic Lupus M32.10 072 ( Infertility, female M97.9 073 ( Interstitial Cystitis N30.11 074 ( Irregular Menstrual Cycle N92.6 075 ( Menopausal Symptoms N95.1 076 ( Hot Flashes N95.1 077 ( Mental Disorder F99 078 ( Insomnia G47.00 079 ( Mouth/Throat/Tongue 080 ( Canker Sores K12.0 081 ( Overweight E66.3 082 ( Underweight R63.6 083 ( Sexual Disorder F66 084 ( Spinal Problems M53.9 085 ( Obesity E66.9 086 ( GERD K21.9 087 ( HIV B20 088 ( Crohns Disease K50.90 089 ( Irritable Bowel Syndrome K58.9 092 ( Normal Pregnancy Z33.1 **only applicable if currently pregnant 093 ( Shingles B02.9 140 ( Migraines G43.909 141 ( Rheumatoid Arthritis M06.9 142 ( Non-Systemic Lupus L93.0 143 ( Multiple Sclerosis G35 144 ( ALS (Lou Gehrigs) G12.21 145 ( Polymyalgia Rheumatica M35.3 146 ( Scleroderma M34.9 171 ( Goiter E04.9 178 ( Raynauds Syndrome I73.00 179 ( Hemochromatosis E83.119 180 ( Thalassemia D56.8 181 ( Brain aneurysm I61.9 If necessary, please state your most significant concern General Health 100 ( Fingernail base is pink 101 ( Fingernail base is purple 102 ( Fingernails have ridges or white spots 103 ( Fingernails are soft 104 ( Fingernails are splitting 105 ( Fingernails peel 106 ( Pale fingernail beds 107 ( Blacks out easily 108 ( Balance problems 109 ( Difficulty walking 110 ( Has tattoos 111 ( Brittle hair 112 ( Dry hair 113 ( Thin hair 114 ( Hair loss 115 ( Drinks alcoholic beverages daily 116 ( Drinks less than 8 glasses of water per day 117 ( Currently on Chemotherapy 118 ( Currently on radiation treatment 119 ( Had chemotherapy in the past 120 ( Has had radiation treatments in the past 121 ( Gained over 20 lbs in the last 12 months 122 ( Somewhat Overweight 123 ( Somewhat Underweight 124 ( Unexplained loss of >20lbs in last 4 months 125 ( Energy level is worse than it was 5 years ago 127 ( Sleeps less than 6 hours per night 128 ( Unable to recall dreams the next day 129 ( Sensitive to chemicals, paint, fumes, cologne 130 ( Had blood transfusion in the past 131 ( Had transplant in the past 138 ( Takes anti-rejection drugs 132 ( Had a major accident or injury 137 ( Sleep Apnea 139 ( Toxic chemical exposure 175 ( Has been out of the country recently 176 ( Had childhood vaccines 177 ( Had a vaccine in the last 12 months 147 ( Had a flu shot last year 182 ( Had a pneumonia vaccine last year 183 ( Had a Hepatitis B vaccine in the last 2 years. Has a family history of: 184 ( Cancer 185 ( Heart Disease 186 ( Diabetes 187 ( Alcoholism 188 ( Depression 189 ( Obesity Lifestyle & Environment Do you use? ( Well Water ( City Water Filtered? ( Yes ( No Filter Type? ________________________ What kind of pipes are in your home? ( Steel ( CPVC ( Copper ( Pex ( Other ______________ What year was your home built? ___________ Any renovations in the past year? ___________________________ Do you use chlorine bleach or other heavy duty cleaners in your home/work? ( Yes ( No Have you ever worked around heavy machinery, plumbing, automotive or the metallurgic industry? ( Yes ( No Explain: ________________________________________________________________________________ Have you ever worked around industrial solvents, chemicals or pesticides? ( Yes ( No Explain: ________________________________________________________________________________ 380 ( Drinks beverages from a can 370 ( Drinks alcohol 371 ( Drinks caffeinated coffee 372 ( Drinks caffeinated pop/soda 373 ( Drinks caffeinated tea 374 ( Drinks decaffeinated coffee 375 ( Drinks decaffeinated pop/soda 376 ( Drinks decaffeinated tea 377 ( Drinks >3 cups of coffee daily 378 ( Drinks >3 cups of tea per day 388 ( Drinks diet pop/soda 379 ( Drinks >1 pop/sodas per day I had 4 alcoholic drinks in one day: 172 ( never 173 ( more than 3 months ago 174 ( less than 3 months ago 381 ( Has >5 alcoholic drinks/week 391 ( Craves sugar / starches 382 ( Currently smokes 383 ( Quit smoking in last 5 years 384 ( Smoked for >5 years 385 ( Smokes >1 pack per day 126 ( Rarely exercises 133 ( Regularly exercises 386 ( Takes Vitamins 134 ( Vegetarian 135 ( Eats no red meat 136 ( Eats no meat, no dairy 387 ( Frequent use of artificial sweeteners 389 ( Anorexia 390 ( Bulimic Surgeries 700 ( Tonsillectomy and/or Adenoids 701 ( Appendix 702 ( Gallbladder 703 ( Thyroid 704 ( Hysterectomy, complete 705 ( Hysterectomy, partial 706 ( Tubal ligation 707 ( Breast implants 708 ( Cancer 709 ( Coronary by-pass 710 ( Spinal surgery 711 ( Extremity surgery 712 ( Hip replacement 713 ( Knee replacement 714 ( Splenectomy 715 ( Radiated thyroid 716 ( Cataract surgery 717 ( Hemorroidectomy 718 ( Bariatric/Weight loss Type: _________________ Gastrointestinal 265 ( 4-5 bowel movements per week 266 ( 3 or less bowel movements per week 267 ( 6 or more bowel movements per week 268 ( Black tarry stools 269 ( Pale or yellow colored stool 270 ( Blood stools 271 ( Constipation 272 ( Hemorrhoids 273 ( Loose bowel movements 274 ( Frequent diarrhea 275 ( Frequent nausea 276 ( Frequent vomiting 277 ( Abdominal gas 278 ( Belching and burping after eating 279 ( Bloated after eating 280 ( Severe abdominal pains 281 ( Stomach ulcers 282 ( Uses digestive aids 283 ( Uses laxatives 284 ( Immediate indigestion upon eating 285 ( Indigestion in 2 hours or more after meals 286 ( Indigestion within 1 hour after meals 287 ( Difficulty swallowing 288 ( Eating relieves fatigue 289 ( Eats when nervous 290 ( Excessive hunger 291 ( Poor appetite 292 ( Experiences fainting spells when hungry 293 ( Feels shaky when hungry 294 ( Frequently drowsy after eating a meal 295 ( Gall bladder disease 296 ( Has had intestinal worms 297 ( Reflux/Hiatal hernia 298 ( Liver disease 299 ( Irritable Bowel Syndrome 300 ( Diverticulitis 301 ( Diverticulosis Respiratory 485 ( Catches severe colds 486 ( Chronic chest condition 487 ( Chronic cough 488 ( Constant runny nose 489 ( COPD 490 ( Difficulty breathing 491 ( Frequent colds 492 ( Frequent nose bleeds 493 ( Frequent sinus infections 494 ( Frequent stuffy nose 495 ( Hay fever 496 ( Nasal polyps 497 ( Night sweats 498 ( Post nasal drip 499 ( Sneezing spells 500 ( Spits up blood 501 ( Spits up phlegm 502 ( Wheezes Mouth and Throat 400 ( Bad breath 401 ( Bitter taste in the mouth in the morning 402 ( Dry mouth 403 ( Excessive saliva 404 ( Sores or cracks in the corners of the mouth 405 ( Glands often swell 406 ( Frequent canker sores 407 ( Frequent fever blisters 408 ( Frequent sore throats 409 ( Frequently has a sore tongue 410 ( Sore gums 411 ( Swollen gums 412 ( Swollen tongue 413 ( Tongue burns 414 ( Tongue has grooves or fissures 415 ( Tongue is coated 416 ( Gums bleed when brushing teeth 417 ( Toothaches 418 ( Amalgam dental fillings 420 ( Other dental fillings (gold, composite, etc) 419 ( Has had root canal(s) Endocrine 245 ( Coarse hair 246 ( Coarse skin 247 ( Diabetic 248 ( Excessive thirst 249 ( Frequently feels cold 250 ( Frequently feels hot 251 ( Gets lightheaded when standing quickly 252 ( Heals slowly 253 ( Unusually jumpy or nervous 254 ( Unusually tired most of the time Cardiovascular 190 ( Cold feet 191 ( Cold hands 192 ( Experiences shortness of breath while sitting still 193 ( Heart skips beats 194 ( Tendency of High blood pressure 195 ( Leg cramps during bedtime 196 ( Leg cramps during daytime 197 ( Low blood pressure at times 198 ( Pain in leg/hips when walking 199 ( Frequent swollen ankles 200 ( Pains in the heart or chest 201 ( Spells of rapid heart rate 202 ( Troubled with blood clots 203 ( Unusually slow pulse rate 204 ( Varicose veins 205 ( Heart palpitations Skin 520 ( Bruises easily 521 ( Excessive perspiration 522 ( Frequent goose bumps 523 ( Has acne 524 ( Has Psoriasis 525 ( Hives 526 ( Itchy skin 527 ( Problems with Eczema 528 ( Has moles which are changing in size and/or color 530 ( Skin is rough, especially on the back of the arms 529 ( Skin eruptions 531 ( Skin is tender 532 ( Sores that heal slowly 533 ( Troubled with boils 534 ( Dry skin Ears 220 ( Discharge from ears 221 ( Hard of hearing 222 ( Punctured ear drum 223 ( Recurrent ear infection 224 ( Ringing or noises in the ears 225 ( Tinnitus Eyes 320 ( Bloodshot eyes 321 ( Blurred vision 322 ( Cross eyes 323 ( Eye pain 324 ( Eyes feel gritty 325 ( Eyes watery 326 ( Mild Glaucoma 327 ( Far sighted 328 ( Developing cataracts 329 ( Mild Macular degeneration 330 ( Itchy eyes 331 ( Near sighted 332 ( Dry Eyes Feet 350 ( Corns 351 ( Frequent foot cramps 352 ( Heel spurs 353 ( Painful feet 354 ( Plantar warts 355 ( Swelling in the feet and/or ankles 356 ( Plantar fasciitis 357 ( Fungal Infection Neuromuscular 440 ( Bites nails 441 ( Frequent muscle soreness 442 ( Muscle spasms 443 ( Muscle weakness 444 ( Tremors 445 ( Frequent headaches 446 ( Often dizzy 447 ( Frequently feels faint 448 ( Has Epilepsy 449 ( Has motion sickness 450 ( Has Osteoarthritis 451 ( Has Rheumatism 452 ( Rheumatoid Arthritis 453 ( Joint stiffness in the morning 454 ( Swollen joints 455 ( Leg pain at rest 456 ( Spinal curvature 457 ( Low back pain 458 ( Neck pain 459 ( Pain between the shoulders 460 ( Shoulder/arm pain 461 ( Numbness/tingling in the body 462 ( Sleep walks 463 ( Stutters or stammers 464 ( Nerve pain Behavior Patterns 150 ( Afraid to eat anywhere except home 151 ( Always needs someone to advise 152 ( Cries often 153 ( Difficulty concentrating 154 ( Difficulty falling asleep 155 ( Difficulty staying asleep 156 ( Easily angered 157 ( Feelings are easily hurt 158 ( Frequently becomes scared for no reason 159 ( Frequently miserable or blue 160 ( Has to be on guard even with friends 161 ( Often annoyed by people 162 ( Recurrent bad dreams 163 ( Sometimes wishes to be dead or away from it all 164 ( Upset by criticism 165 ( Poor memory 166 ( Scared to be alone 167 ( Strange people or places cause fear 168 ( Under considerable emotional stress 169 ( Unhappy when others are happy 170 ( Brain fog Urinary 555 ( Urinates more than 2 times per night 556 ( Bed wetting 557 ( Blood in the urine 558 ( Difficulty starting urination 559 ( Painful urination 560 ( Frequent urination 561 ( Troubled by urgent urination 562 ( Incontinence when sneezing or laughing 563 ( Loses bladder control 564 ( Frequent bladder infections 565 ( Frequent kidney infections 566 ( Kidney stones Men Only 585 ( Difficulty completing intercourse 586 ( Difficulty getting or keeping an erection 587 ( Discharge from the urethra 588 ( Had a vasectomy 589 ( Had difficulty fathering children 590 ( Lumps in the testicles 591 ( Painful genitals 592 ( Prostate troubles 593 ( Sores on external genitalia 594 ( Herpes 595 ( Sexual diseases Women Only 610 ( Heavy hair growth on face or body 611 ( Cycles are every 27-29 days 612 ( Abnormal cycle >29 days and/or <26 days 613 ( PMS 614 ( Menstrual cramps 615 ( Painful periods 616 ( Acne worse at menstruation 617 ( Excessive menstrual flow 618 ( Retains fluid during periods 619 ( Pre-menstrual depression 620 ( Currently taking birth control medication 621 ( Has taken birth control medication more than 1 year 622 ( Has taken birth control medication within the last year 623 ( Has had miscarriage 624 ( Hot flashes 625 ( Takes hormone replacement medication 627 ( Diminished sexual desire 628 ( Painful intercourse 629 ( Poor or infrequent orgasm 630 ( Lumps in the breasts 631 ( Tender breasts 633 ( Vaginal discharge 634 ( Bloody spotting discharge 635 ( Yeast infections 636 ( Sores on external genitalia 637 ( Herpes 638 ( Sexual diseases 639 ( Endometriosis 640 ( Breast reduction 641 ( Breast augmentation 642 ( Abortion 643 ( D&C 644 ( Tubal pregnancy 645 ( Uterine fibroids 646 ( Ovarian fibroids 647 ( Breast fibroids 648 ( Currently Breastfeeding Medications Please list all drugs you are currently taking on a daily basis. DRUG PRESCRIBED FOR: HOW LONG _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ Please list all drugs taken within the last year and/or you take as needed including over the counter drugs, antibiotics, aspirin, inhalers, etc. DRUG PRESCRIBED FOR: HOW LONG _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ Allergies Please list any known allergies (ex. foods, medications, spices, environmental, etc.) ( Dairy ( Eggs ( Garlic (Gluten ( Mold ( Peanut ( Ragweed ( Shellfish ( Soy ( Sulfa drugs ( Tree nuts ( Wheat ( Other _____________________________________________________________________ Supplements Please list all vitamins/herbs/supplements you are currently taking and dosages. VITAMIN BRAND DOSAGE _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________ _______________ __________________________________ _______________      PAGE  PAGE 6 Van D. Merkle, D.C., C.C.N., D.A.C.B.N., D.A.C.B.I. Andrew Dyer, D.C. Tracey C. 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