review-of-symptoms.pdf

©Endocrine Wellness, LLC 2017

REVIEW OF SYMPTOMS

Patient Name: __________________________________ Date:_______________

Check (√) what applied to you in the past. Circle what applies presently.

GENERAL:

! Fever

! Chills/Cold all over

! Aches/Pains

! General Weakness

! Difficulty sweating

! Excessive Sweating

! Swollen Glands

! Cold hands & Feet

! Fatigue

! Difficulty falling asleep

! Sleepwalker

! Nightmares

! No dream recall

! Early waking

! Daytime sleepiness

! Distorted vision

SKIN:

! Cuts heal slowly

! Bruise easily

! Rashes

! Pigmentation

! Changing Moles

! Calluses

! Eczema

! Psoriasis

! Dryness/cracking skin

! Oiliness

! Itching

! Acne

! Boils

! Hives

! Fungus on Nails

! Peeling Skin

! Shingles

! Nails Split

! White Spots/Lines on Nails

! Crawling Sensation

! Burning on Bottom of Feet

! Athletes Foot

! Cellulite

! Bugs love to bite you

! Bumps on back of arms & front of thighs

! Skin cancer

! Strong body odor

! Is your skin sensitive to:

! Sun

! Fabrics

! Detergents

! Lotions/Creams

HEAD:

! Poor Concentration

! Confusion

! Headaches:

! After Meals

! Severe

! Migraine

! Frontal

! Afternoon

! Occipital

! Afternoon

! Daytime

! Relieved by:

! Eating Sweets

! Concussion/Whiplash

! Mental sluggishness

! Forgetfulness

! Indecisive

! Face twitch

! Poor memory

! Hair loss

EYES:

! Feeling of sand in eyes

! Double vision

! Blurred vision

! Poor night vision

! See bright flashes

! Halo around lights

! Eye pains

! Dark circles under eyes

! Strong light irritates

! Cataracts

! Floaters in eyes

! Visual hallucinations