"Patient Medical Symptoms Checklist Template"

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PATIENT MEDICAL SYMPTOMS
Please check all symptoms that pertain to you at the current time.
Cold hands/feet
Bad breath
Fatigue
Large appetite
Feverish in the afternoon or flushes
Mouth, canker or cold sores
Heat sensation in hands, feet, chest
Bleeding, swollen or painful gums
Night sweats
Heartburn/belching
Catch colds easily
Stomach pain
Sweats easily during daytime
Vomiting/nausea
Dizziness
Diarrhea alternating with constipation
See floating black spots
Tight/suffocating feeling in chest
_________________________________________
Bitter taste in mouth
Palpitations
Blood shoot eyes/dry eyes
Sore on tongue
Anger easily
Restlessness
Skin rashes
Anxiety
Headache
Chest pain
Numbness of hands and feet
Insomnia
Muscle spasms, twitching, cramping
__________________________________________
Cough
Seizures/convulsions
Sinus congestion
Sore, cold or weak knees
Dry mouth, throat, nose, or skin
Low back pain
Allergies seasonal or food
Frequent urination
Chills and fever
Get up more than once a night to urinate
Stiff neck/shoulders
Lack of bladder control
Sore throat
Memory problems
Difficult breathing
Hair loss
___________________________________________
Ringing in ears
Low appetite
Urine is:
Loose stools
Normal color
Clear
Constipation
Dark yellow
Reddish
Abdominal bloating or gas after eating
Cloudy
Scanty
Feeling tired after eating
Bad odor
Prolapsed organs (previously diagnosed)
Burning
Painful
Bruises easily
Difficult
Urgent
General feeling of heaviness in body
Mental heaviness or fogginess
Libido (sex drive) is:
Swollen hands/feet
Normal
Low
High
Burning sensation after eating
PATIENT MEDICAL SYMPTOMS
Please check all symptoms that pertain to you at the current time.
Cold hands/feet
Bad breath
Fatigue
Large appetite
Feverish in the afternoon or flushes
Mouth, canker or cold sores
Heat sensation in hands, feet, chest
Bleeding, swollen or painful gums
Night sweats
Heartburn/belching
Catch colds easily
Stomach pain
Sweats easily during daytime
Vomiting/nausea
Dizziness
Diarrhea alternating with constipation
See floating black spots
Tight/suffocating feeling in chest
_________________________________________
Bitter taste in mouth
Palpitations
Blood shoot eyes/dry eyes
Sore on tongue
Anger easily
Restlessness
Skin rashes
Anxiety
Headache
Chest pain
Numbness of hands and feet
Insomnia
Muscle spasms, twitching, cramping
__________________________________________
Cough
Seizures/convulsions
Sinus congestion
Sore, cold or weak knees
Dry mouth, throat, nose, or skin
Low back pain
Allergies seasonal or food
Frequent urination
Chills and fever
Get up more than once a night to urinate
Stiff neck/shoulders
Lack of bladder control
Sore throat
Memory problems
Difficult breathing
Hair loss
___________________________________________
Ringing in ears
Low appetite
Urine is:
Loose stools
Normal color
Clear
Constipation
Dark yellow
Reddish
Abdominal bloating or gas after eating
Cloudy
Scanty
Feeling tired after eating
Bad odor
Prolapsed organs (previously diagnosed)
Burning
Painful
Bruises easily
Difficult
Urgent
General feeling of heaviness in body
Mental heaviness or fogginess
Libido (sex drive) is:
Swollen hands/feet
Normal
Low
High
Burning sensation after eating
Women only:
Men Only:
1. Are you pregnant now?
Discharge
Yes
No
Pain or swelling of testicles
2. Number of children:_________
Ejaculatory problems
3. Number of pregnancies:______
Impotence/erectile dysfunction
4. Age of first period:__________
5. Age of menopause if
applicable:________________
6. Is your menses cycle regular?
Yes
No
a. Average number of days in flow:____
b. The flow is:
Normal
Heavy
Light
c. The color is:
red
dark
purple
light brown
brown
d. Do you have the following menstruation
related symptoms?
Blood clots
Cramps
Nausea
Breast distension
PMS
Bleeding between periods
Signature __________________________
Heavy vaginal discharge between periods
Date_______________________________
e. Birth control:_______________________
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