• Adult Wellness Questionnaire

  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today's Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • CONSTITUTIONAL

    In the past year have you....?
  • Do you have excess fatigue?
  • Has your weight changed in the last year?
  • Have you had fevers, chills or night sweats?

  • SKIN

    In the past year have you....?
  • Have you had problems with dry skin, rash, eczema or itching?
  • Have you had skin lesions that have changed in size, shape or color?
  • Are you concerned about any skin lesions that you think could be cancerous?

  • EYES

    In the past year have you....?
  • Have you had problems with loss of vision, double vision or blurred vision?
  • Do you wear glasses or contacts?

  • HEAD AND NECK

    In the past year have you....?
  • Have you had problems hearing?
  • Have you had ringing in your ears?
  • Have you had problems with sense of smell or nose bleeds?
  • Have you had sinus infections or congestion?
  • Have you had problems with teeth, gum or throat?
  • Have you had problems with swallowing or neck pain?
  • Have you had frequent hoarseness, or change in character of your voice?

  • CARDIOVASCULAR

    In the past year have you....?
  • Do you notice chest pain, ache, pressure, discomfort or tightness?
  • Do you notice irregular or rapid heart beating?
  • Have you noticed swelling in your feet, ankles or hands?
  • Has your exercise tolerance changed?

  • RESPIRATORY

    In the past year have you....?
  • Have you had a cough, wheezing or shortness of breath?
  • Have you coughed up any blood?
  • Do you use tobacco products?

  • GASTROINTESTINAL

    In the past year have you...?
  • Do you have trouble swallowing?
  • Are you bothered by heartburn?
  • Have you had black tarry stools?
  • Have you had a change in bowel movements?
  • Have you passed blood with one or more bowel movements?
  • Do you have problems with either diarrhea or constipation?

  • NEUROLOGICAL

    In the past year have you....?
  • Have you had frequent or periodic headaches?
  • Have you had dizziness or passing out?
  • Have you had problems with memory?
  • Do you have a tremor or shaking of hands?
  • Have you had numbness, tingling or weakness of the extremities?

  • PSYCHIATRIC

    In the past year have you....?
  • Do you feel depressed?
  • Do you feel stressed?
  • Do you cry frequently?
  • Do you have problems with appetite?
  • Is anxiety a problem for you?
  • Do you have trouble sleeping?
  • Are you dissatisfied with our life?
  • Do you desire counseling?

  • ENDOCRINE

    In the past year have you....?
  • Do you have excessive thirst or urination?
  • Do you have heat or cold intolerance
  • Unexplained hair loss?

  • HEMATOLOGICAL

    In the past year have you....?
  • Do you bruise easily or have trouble with bleeding>
  • Have you noticed any enlarged lymph nodes?

  • ALLERGIC/IMMUNOLOGIC

    In the past year have you....?
  • Do you have seasonal allergy symptoms, congestion, itchy eyes or sneezing?
  • Have you had wheezing at rest or with activity?

  • MUSCULOSKELETAL

    In the past year have you....?
  • Have you had joint pain, stiffness, redness or swelling?
  • Have muscle pain, weakness or cramps?
  • Have you had neck or back pain?
  • Have you had pain in the legs while walking?

  • MEN - GENITOURINARY

    In the past year have you....?
  • Do you have to urinate at night?
  • Do you have problems emptying the bladder completely?
  • In the past year have you had a kidney, bladder or prostate infection?
  • Have you had blood in the urine or semen?
  • Do you have abnormal sexual drive, difficulty with erections?

  • WOMEN - GENITOURINARY

    In the past year have you....?
  • Do you have problems with control of urination?
  • Do you have to urinate at night?
  • In the past year, have you had a kidney or bladder infection?
  • Have you had blood in the urine?
  • Have you had an unusual discharge from the vagina?
  • Do you have discomfort with intercourse or decrease in sexual drive?
  • Have you had hot flashes, sweating at night or vaginal dryness?
  • Date of last menstrual period?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you had vaginal spotting/bleeding at times other than a menstrual period?
  • Have your menstrual periods changed in frequency, regularity or amount?
  • Do you have menstrual tension or other symptoms at the time of your period?
  • Have you had recent breast tenderness, lumps or nipple discharge?
  • Do you do a self-breast exam?
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