Patient Follow Up Form

General, constitutional

Good general health lately NoYes

Recent weight change NoYes

Fever/chills NoYes

Fatigue NoYes

Musculoskeletal

Joint pain NoYes

Joint stiffness or swelling NoYes

Weakness of muscles/joints NoYes

Muscle pain or cramps NoYes

Back pain NoYes

Difficulty in walking NoYes

Eyes and vision

Eye disease or injury NoYes

Wear glasses or contact lenses NoYes

Blurred or double vision NoYes

Glaucoma NoYes

Skin and breasts

Rash or itching NoYes

Change in skin color NoYes

Varicose veins NoYes

Breast pain NoYes

Ears, nose, throat

Hearing loss NoYes

Ringing in the ears NoYes

Sinus problems NoYes

Nose bleeds NoYes

Bleeding gums NoYes

Sore throat or voice change NoYes

Neurological

Frequent or recurrent headaches NoYes

Lightheaded or dizzy NoYes

Convulsions or tingling sensations NoYes

Tremors NoYes

Strokes/TIA NoYes

Head injury NoYes

Genitourinary

Frequent urination NoYes

Burning or painful urination NoYes

Blood in urine NoYes

Sexual difficulty NoYes

Irregular periods NoYes

Psychiatric

Memory loss or confusion NoYes

Nervousness/anxiety NoYes

Depression NoYes

Sleep problems NoYes

Snoring NoYes

Respiratory

Frequent coughing NoYes

Spitting up blood NoYes

Shortness of breath NoYes

Asthma or wheezing NoYes

Endocrine

Glandular or hormone problem NoYes

Thyroid disease NoYes

Diabetes NoYes

Excessive thirst or urination NoYes

Heat or cold intolerance NoYes

Gastrointestinal

Loss of appetite NoYes

Constipation NoYes

Nausea or vomiting NoYes

Frequent diarrhea NoYes

Blood in stool NoYes

Stomach pain NoYes

Hematologic/Lymphatic

Slow to heal after cuts NoYes

Easily bruise or bleed NoYes

Anemia NoYes

Phlebitis NoYes

Transfusion NoYes

Swollen glands NoYes