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Patient Follow Up Form













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    Please indicate below. Are you currently experiencing any of these symptoms:

    General, constitutional

    Good general health lately

    Recent weight change

    Fever/chills

    Fatigue

    Musculoskeletal

    Joint pain

    Joint stiffness or swelling

    Weakness of muscles/joints

    Muscle pain or cramps

    Back pain

    Difficulty in walking

    Eyes and vision

    Eye disease or injury

    Wear glasses or contact lenses

    Blurred or double vision

    Glaucoma

    Skin and breasts

    Rash or itching

    Change in skin color

    Varicose veins

    Breast pain

    Ears, nose, throat

    Hearing loss

    Ringing in the ears

    Sinus problems

    Nose bleeds

    Bleeding gums

    Sore throat or voice change

    Neurological

    Frequent or recurrent headaches

    Lightheaded or dizzy

    Convulsions or tingling sensations

    Tremors

    Strokes/TIA

    Head injury

    Genitourinary

    Frequent urination

    Burning or painful urination

    Blood in urine

    Sexual difficulty

    Irregular periods

    Psychiatric

    Memory loss or confusion

    Nervousness/anxiety

    Depression

    Sleep problems

    Snoring

    Respiratory

    Frequent coughing

    Spitting up blood

    Shortness of breath

    Asthma or wheezing

    Endocrine

    Glandular or hormone problem

    Thyroid disease

    Diabetes

    Excessive thirst or urination

    Heat or cold intolerance

    Gastrointestinal

    Loss of appetite

    Constipation

    Nausea or vomiting

    Frequent diarrhea

    Blood in stool

    Stomach pain

    Hematologic/Lymphatic

    Slow to heal after cuts

    Easily bruise or bleed

    Anemia

    Phlebitis

    Transfusion

    Swollen glands




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