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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
Patient Name*
History Questionnaire Continued
Genital (women)
Neurological
Irregular Periods .........
No
Yes
Problems with balance
No
Yes
Painful Periods .........
No
Yes
Trouble with memory ...
No
Yes
Infertility problems .....
No
Yes
Headaches ...........
No
Yes
PMS symptoms ..........
No
Yes
Tremors/Shakes .........
No
Yes
Lack of sex drive ......
No
Yes
Speech problems ...........
No
Yes
Vaginal discharge ......
No
Yes
Endocrine
Skin/Breast
Diabetes ..............
No
Yes
Eczema ..............
No
Yes
Hungry all the time .........
No
Yes
Psoriasis ........
No
Yes
Thirsty all the time ....
No
Yes
Rash ......
No
Yes
Thyroid problems ......
No
Yes
Tatoos ........
No
Yes
Heat/Cold intolerance ..
No
Yes
Painful breasts .....
No
Yes
Weight gain/Weight loss
No
Yes
Nipple discharge ..
No
Yes
History of breast biopsy
No
Yes
Hematology/Lyphatic
Anemia ......
No
Yes
Muscle/Joint/Bones
Easy bruising ......
No
Yes
Joint inflammation ....
No
Yes
Back pain .....
No
Yes
Psychiatric
Joint stiffness .....
No
Yes
Depression ...
No
Yes
Muscle weakness ........
No
Yes
Anxiety ...
No
Yes
Trouble with your feet
No
Yes
Hearing voices ....
No
Yes
Feeling of hopelessness ...
No
Yes
Allergy/Immunology
Feeling stressed ......
No
Yes
Allergies ......
No
Yes
Recurrent infections ......
No
Yes
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