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2. Eyes
eye pain light sensitivity
4. Heart
chest pain racing/skipping heart beats lightheadedness difficulty breathing when you lie down fainting
5. Lungs
cough shortness of breath wheezing snoring
12. Endocrine
cold intolerance heat intolerance excessive urination excessive thirst
6. Bowels
indigestion/heartburn/reflux nausea vomiting abdominal (belly) pain diarrhea
7. Urinary System
inability to empty bladder difficulty holding urine trouble starting stream painful urination
14. Allergies
persistent infections seasonal allergies HIV exposure Problems not listed above: ________________________________________________
8. Musculoskeletal
joint pain joint swelling muscle weakness gout
9. Skin
suspicious areas
Reaction
Treatment
Medication / Dosage
Frequency
E. Lifestyle
Alcohol Smoking Exercise Drink(s) Per Week: Pack(s) Per Day: Type(s) of Exercise: Number of Years: Number of Years: Days Per Week: