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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 

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