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History Questionnaire
History Questionnaire(Continued)
History Personal
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Kevin Theodorou, M.D.
10585 N Tatum Blvd, D-137
Paridise Valley, AZ 85253
History Questionnaire
Patient Name*
Date*
Chief Complaints: (please list all symptoms)
Please answer each of the following questions by checking yes or no.
System Review
(Do you have any of the following symptoms)
General
Respiratory
Fever .......................
No
Yes
Chronic cough ..............
No
Yes
Chills .......................
No
Yes
Chronic Sputum ............
No
Yes
Weight Loss .................
No
Yes
Cough up blood ...........
No
Yes
Night Sweats ...............
No
Yes
Wheezing ..............
No
Yes
Difficulty Sleeping ......
No
Yes
Clot in leg or lung ...........
No
Yes
Eyes
Gastrointestinal
Blurred Vision ..............
No
Yes
Poor Appitite ...........
No
Yes
Double Vision ..............
No
Yes
Heartburn ................
No
Yes
Halos around lights ........
No
Yes
Difficulty swallowing ......
No
Yes
Pain in your eyes ......
No
Yes
Nausea or vomiting ......
No
Yes
Ear/Nose/Mouth/Throat
Abdominal pain ......
No
Yes
Ear pain ..............
No
Yes
Diarrhea ...........
No
Yes
Drainage from ear .....
No
Yes
Constipation .............
No
Yes
Hearing Difficulty .....
No
Yes
Change in bowel habits ...
No
Yes
Ringing in ear ............
No
Yes
Red blood from rectum ...
No
Yes
Runny nose ..............
No
Yes
Hemorrhoids ................
No
Yes
Nosebleeds ........
No
Yes
Black or dark stools ...
No
Yes
Sinus trouble ......
No
Yes
Kidney
Mouth/Teeth problem ....
No
Yes
Difficulty passing urine ....
No
Yes
Persistent Hoarseness .....
No
Yes
Getting up at night to urinate
No
Yes
Food gets stuck .....
No
Yes
Difficulty controlling urine
No
Yes
Cardiovascular
Pain/burning with urination
No
Yes
Chest pain ........
No
Yes
Blood in urine ...
No
Yes
Chest heaviness ......
No
Yes
Genital (men)
Skipped heart beats ..
No
Yes
Lack of sex drive ....
No
Yes
Shortness of breath ...
No
Yes
Impotence
No
Yes
Swollen Ankles .....
No
Yes
Lump on testicle ...
No
Yes
Leg cramps ..............
No
Yes
Sore on penis ......
No
Yes
Dizzy spells .....
No
Yes
Discharge from penis ...
No
Yes
Fainting spells .....
No
Yes
Waking at night short of breath
No
Yes
Email*
Password*
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