"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:_______________________
Medical Checklist Template

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