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Please check YES or NO
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Constitutional
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Do you have current fever or chills
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Do you have recent unintentional weight loss?
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Do you have excessive Lethargy/Fatigue?
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Do you have generalized muscle weakness?
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Cardiovascular System
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Are you having recent chest pain?
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Do you have swelling of feet and legs?
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Do you have irregular heart beat?
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Have you had a heart attack?
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Do you get leg pain or cramps when walking less then 2 city blocks?
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Have you had a stroke(CVA)?
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Respiratory System
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Do you have shortness of breath?
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Do you have asthma ?
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Do you have recent cough/sputum production?
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Do you have Chronic Obstructive Pulmonary Disease.
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Gastrointestinal System
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Do you have peptic ulcer or gastritis?
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Do you have hepatitis or liver disease?
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Genitourinary System
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History of kidney disease or renal insufficiency ?
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Hematologic
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Do you have history of blood clot?
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Do you have bleeding disorder?
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Do you have anemia?
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Neurological
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Do you have history of seizure disorder?
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Do you get foot or leg numbness?
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Do you get Radiating pain from back to leg/foot?
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Do you get leg weakness?
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Musculoskeletal System
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History of osteoporosis ?
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Do you get joint swelling or pain ?
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Do you have a history of gout ?
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Do you have lower back pain?
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Do you have history of rheumatoid arthritis ?
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Integument
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Do you have history of skin cancer ?
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Change in moles or skin color ?
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