Do you currently have, or have you had, problems with:
CONSTITUTIONAL	CIRCLE	ONE	NEUROLOGIC	CIRCLE	ONE
Weight Gain	Yes	No	Numbness	Yes	No
Weight Loss	Yes	No	Weakness	Yes	No
Fever	Yes	No	Stroke	Yes	No
Night Sweats	Yes	No	Seizures	Yes	No
Insomnia	Yes	No	Headaches	Yes	No
EYES			PSYCHIATRIC
Double Vision	Yes	No	Depression	Yes	No
Visual Loss	Yes	No	Other	Yes	No
ENT			RESPIRATORY
Ear Pain	Yes	No	Asthma	Yes	No
Hearing Loss	Yes	No	COPD	Yes	No
Noise/Ringing in Ears	Yes	No	Cough	Yes	No
Dizziness	Yes	No	TB	Yes	No
Vertigo	Yes	No	Pneumonia	Yes	No
Nasal Congestion	Yes	No	Snoring	Yes	No
Nasal Drainage	Yes	No
Sore Throat	Yes	No	GASTROINTESTINAL
Trouble Swallowing	Yes	No	Indigestion/Heartburn	Yes	No
Hoarseness	Yes	No	Acid Reflux	Yes	No
Speech Problem	Yes	No	Ulcers	Yes	No
			Hepatitis	Yes	No
ALLERGIC/IMMUNOLOGIC
Sneezing	Yes	No	GENITOURINARY
Itchy Eyes/Nose	Yes	No	Bladder Trouble	Yes	No
Itchy Throat	Yes	No	Prostate Disease	Yes	No
Skin Rash	Yes	No	Kidney Disease	Yes	No
HIV	Yes	No
Cancer	Yes	No	MUSCULOSKELETAL
			Arthritis	Yes	No
CARDIOVASCULAR
Chest Pain or Angina	Yes	No	ENDOCRINE
Heart Trouble	Yes	No	Diabetes	Yes	No
Rheumatic Fever	Yes	No	Thyroid Disease	Yes	No
Heart Murmur	Yes	No
High Blood Pressure	Yes	No	HEMATOLOGIC
			Blood Disorder	Yes	No
			Easy Bleeding	Yes	No
The above information is accurate to the best of my knowledge.
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Patient Signature
I have reviewed the above information with the patient. Physician's Signature_____________________________