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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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