| Document Date: 2015-02-02 17:24:05
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City Rheumatology / / Company GM / / Country United States / / IndustryTerm food intolerance / oxygen or other medical equipment / list food / / MedicalCondition Cystic fibrosis Diabetes Mellitus High cholesterol High blood pressure Frequent Pneumonia Pulmonary embolism / sputum Chest tightness Cough / choking / No No No Cardiovascular Chest pain / stool Constipation Diarrhea / Cancer / Acne / Pertussis / Shortness of breath / HPV / chicken pox / heaviness Palpitations Fainting / Thalassemia Thrombocytopenia Thrombophilia Transfusions Tuberculosis / Gastric Ulcers GERD / nausea / Lymphoma - Melanoma - Prostate / Bulimia Anxiety Disorder Arteriovenous Malformations Arthritis Asthma Bipolar Disorder Bleeding Disorder Bronchiectasis Cancer / Ear pain / difficult Erection problems Vaginal discharge / Allergy / indigestion Vomiting / pain / Kidney Failure / non-healing ulcers Yes Yes Yes No No No Neurologic Seizures Coughing / Fatigue / Valve Defects Hemochromatosis Hemorrhoids Hepatitis HIV / Reactive Arthritis Recurrent Infections Restless Leg Syndrome Rheumatoid Arthritis Sarcoidosis Schizophrenia Scleroderma Scoliosis Seizure Disorder Sickle Cell Sinusitis Sjogren’s Disease Skin Disorders / near fainting / diseases / Eye pain / Coronary artery disease / AIDS / Psoriasis / Emphysema Pulmonary / Other diseases / breath Wheezing Chest pain / sensation Hallucinations Numbness / Joint pain / Other cancer / Injuries / Pulmonary Embolism Endocarditis Endometriosis End Stage Renal Disease Erectile Dysfunction Esophageal Dysfunction Fibromyalgia Gallstones Gastritis / / MedicalTreatment Immunization / Radiation Therapy / drainage / Vaccination / / Organization High School / / Person Bro Sis Son Dau Allergic / Sister / Grandmother / Maternal Paternal Siblings Children Mom / Chicken Pox (Varicella) / Paternal Siblings Children Mom / Brother / Daughter / Dau Allergic Rhinitis Asthma Autoimmune / Grandfather / Son Dau Allergic Rhinitis Asthma / / Position Name Physician / Name Address Address Phone Phone Fax Fax Email Email Physician / Care Physician / Physician / Surgeon / / Product Penicillin / Lipitor / / Technology Radiation / cellular telephone / Chemotherapy / Dialysis / /
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Patient Name: ________________________ Date of Birth: _________________________ Cell Phone: (_____)____________________ ▲ Please use blue or black ink ADULT PATIENT QUESTIONNAIRE