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  • San Diego Family Dermatology Medical History Form

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  • Please carefully review this symptom list:

    General: weight change, change in energy, change in strength or exercise
    tolerance

    Head: headaches, vertigo, head injury

    Eyes: change in vision, seeing double, tearing, partial vision loss, eye pain Ears:
    change in hearing, ringing, bleeding, vertigo/dizziness Nose: bleeding noses, running nose, obstruction, discharge

    Mouth: dental difficulties, gingival bleeding, use of dentures

    Neck: stiffness, pain, tenderness, masses

    Breast: lumps, tenderness, swelling, nipple discharge

    Chest: shortness of breath, wheezing, coughing up blood, chronic coughing

    Heart: chest pains, palpitations, syncope

    Abdomen: change in appetite, trouble swallowing, abdominal pains, bowel habit
    changes, blood in your stool

    GU: urinary urgency, pain with urinating, change in nature of urine

    Women Gyn: change in menses, pain with menses, vaginal discharge, pelvic pain

    Musculoskeletal: pain in muscles or joints, limitation of range of motion, numbness

    Neurologic: weakness, tremor, seizures, changes in mentation, lack of coordination

    Psychiatric: depressive symptoms, changes in sleep habits, changes in thought content

    Other: excessive sweating

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