Patient Symptom Survey
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Height
Example: 5'9"
Weight
Example: 170 lbs.
Primary Complaints
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[001] Skin Disorder
[002] Acne
[003] Psoriasis
[004] Urticaria (Hives)
[005] ADD/ADHD
[006] Allergies, Unspecified
[007] Allergic Rhinitis from food
[008] Sinusitis
[009] Alzheimer’s
[010] Poor Concentration/ Memory
[011] Parkinson’s Disease
[012] Anemia
[013] Arthritic Disorder
[014] Osteoporosis
[015] Asthma
[016] Emphysema
[017] Cancer
[018] Breast Cancer
[019] Prostate Cancer
[020] Lung Cancer
[021] Colon and Rectal Cancer
[022] Skin Cancer
[023] Leukemia
[024] Lymphoma
[025] Brain Tumor
[027] Anxiety Disorder
[028] Autism
[029] Hyperglycemia (High blood sugar)
[030] Diabetes Type I
[031] Diabetes Type II
[033] Edema
[034] Eczema
[035] Chronic Fatigue
[036] Circulatory Disorder
[037] Heart Disease
[038] High Cholesterol
[039] High Blood Pressure
[040] Low Blood Pressure
[041] Tachycardia (High Heart Rate)
[042] Numbness
[043] Constipation
[044] Indigestion
[045] Ulcerative Colitis
[046] Depression
[047] Diabetes Mellitus
[048] Hypoglycemia (Low Blood Sugar)
[049] Dizziness/ Balance Problem
[050] Ear Infection
[051] Epstein Barr
[052] Eye Problems
[053] Cataracts
[054] Glaucoma
[055] Macular Degeneration
[056] Fever
[057] Fibromyalgia
[058] Gallbladder Disorder
[059] Gout
[060] Headaches
[061] Hearing Loss
[062] Infertility (Male)
[063] Prostate Disorder
[064] Liver Disease
[065] Hepatitis
[066] Hepatitis B
[067] Hepatitis C
[068] Kidney Disorder
[069] Hyperthyroidism
[070] Hypothyroidism
[071] Systemic Lupus
[072] Infertility (Female)
[073] Interstitial Cystitis
[074] Irregular Menstrual Cycle
[075] Menopausal Symptoms
[076] Hot Flashes
[077] Mental Disorder
[078] Insomnia
[079] Mouth/ Throat/ Tongue Sores
[080] Canker Sores
[081] Overweight
[082] Underweight
[083] Sexual Disorder
[084] Spinal Problems
[085] Obesity
[086] GERD
[087] HIV
[088] Crohn’s Disease
[089] Irritable Bowel Syndrome
[090] General Good Health
[091] Desires Nutritional & Metabolic Analysis
[092] Pregnant (Normal Pregnancy)
[093] Shingles
[140] Migraines
[141] Rheumatoid Arthritis
[142] Non-Systemic Lupus
[143] Multiple Sclerosis
[144] ALS
[145] Polymyalgia Rheumatica
[146] Scleroderma
[171] Goiter
[178] Raynaud’s Syndrome
[179] Hemochromatosis
[180] Thalassemia
[181] Brain Aneurysm
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General Health
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[100] Fingernail base is pink
[101] Fingernail base is purple
[102] Fingernails have ridges or white spots
[103] Fingernails are soft
[104] Fingernails are splitting
[105] Fingernails peel
[106] Pale fingernail beds
[107] Blacks Out Easily
[108] Balance Problems
[109] Difficulty Walking
[110] Has Tattoos
[111] Brittle Hair
[112] Dry Hair
[113] Thin Hair
[114] Hair Loss
[115] Drinks alcoholic beverages daily
[116] Drinks less than 8 glasses of water per day
[117] Currently on Chemotherapy
[118] Currently on Radiation Treatment
[119] Had Chemotherapy in the past
[120] Had Radiation Treatments in the past
[121] Gained over 20 lbs. In the last 12 months
[122] Somewhat Overweight
[123] Somewhat Underweight
[124] Unexplained loss of >20 lbs. in last 4 months
[125] Energy level is worse than it was 5 years ago
[126] Rarely Exercises
[127] Sleeps less than 6 hours per night
[128] Unable to recall dreams the next day
[129] Sensitive to chemicals, paint fumes, cologne
[130] Had blood transfusion in the past
[131] Had transplant in the past
[132] Had a major accident or injury
[133] Regularly Exercises
[134] Vegetarian
[135] Eats no red meat
[136] Eats no red meat and no dairy
[137] Sleep Apnea
[138] Takes anti-rejection drugs
[139] Toxic Chemical Exposure
[147] Had a flu shot in the last year
[175] Has been out of the country recently
[176] Had Childhood Vaccines
[177] Had a vaccine in the last 12 months
[182] Had a pneumonia vaccine in the last year
[183] Had a Hepatitis B vaccine in the last 2 years
[184] Family History of Cancer
[185] Family History of Heart Disease
[186] Family History of Diabetes
[187] Family History of Alcoholism
[188] Family History of Depression
[189] Family History of Obesity
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Lifestyle
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[370] Drinks Alcohol
[371] Drinks Caffeinated Coffee
[372] Drinks Caffeinated Pop/Soda
[373] Drinks Caffeinated Tea
[374] Drinks Decaffeinated Coffee
[375] Drinks Decaffeinated Pop/Soda
[376] Drinks Decaffeinated Tea
[377] Drinks >3 cups of coffee per day
[378] Drinks >3 cups of tea per day
[379] Drinks >1 pop/soda per day
[380] Drinks beverages from a can
[381] Has >5 alcoholic drinks per week
[382] Currently Smokes
[383] Quit smoking in the last 5 years
[384] Smoked for >5 years
[385] Smokes >1 pack per day
[386] Takes Vitamins
[387] Frequent use of artificial sugars
[388] Drinks Diet Pop/Soda
[389] Anorexia
[390] Bulimic
[391] Craves Sugar/Starches
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Surgeries
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[700] Tonsillectomy and/or Adenoids
[701] Appendix
[702] Gallbladder
[703] Thyroid
[704] Hysterectomy, Complete
[705] Hysterectomy, Partial
[706] Tubal Ligation
[707] Breast Implants
[708] Cancer
[709] Coronary By-Pass
[710] Spinal Surgery
[711] Extremity Surgery
[712] Hip Replacement
[713] Knee Replacement
[714] Splenectomy
[715] Radiated Thyroid
[716] Cataract Surgery
[717] Hemorrhoidectomy
[718] Bariatric/ Weight Loss
Other
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Gastrointestinal
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[265] 4-5 bowel movements per week
[266] 3 or less bowel movements per week
[267] 6 or more bowel movements per week
[268] Black Tarry Stools
[269] Pale or Yellow Colored Stools
[270] Blood Stools
[271] Constipation
[272] Hemorrhoids
[273] Loose Bowel Movements
[274] Frequent Diarrhea
[275] Frequent Nausea
[276] Frequent Vomiting
[277] Abdominal Gas
[278] Belching and burping after eating
[279] Bloated after eating
[280] Severe Abdominal Pains
[281] Stomach Ulcers
[282] Uses Digestive Aids
[283] Uses Laxatives
[284] Immediate indigestion upon eating
[285] Indigestion in 2 hours or more after meals
[286] Indigestion within 1 hour after meals
[287] Difficulty Swallowing
[288] Eating relieves fatigue
[289] Eats when nervous
[290] Excessive Hunger
[291] Poor Appetite
[292] Experiences fainting spells when hungry
[293] Feels shaky when hungry
[294] Frequently drowsy after eating a meal
[295] Gallbladder Disease
[296] Has had intestinal worms
[297] Reflux/ Hiatal Hernia
[298] Liver Disease
[299] Irritable Bowel Syndrome
[300] Diverticulitis
[301] Diverticulosis
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Respiratory
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[485] Catches severe colds
[486] Chronic Chest Condition
[487] Chronic Cough
[488] Constant Runny Nose
[489] COPD
[490] Difficulty Breathing
[491] Frequent Colds
[492] Frequent Nose Bleeds
[493] Frequent Sinus Infections
[494] Frequent Stuffy Nose
[495] Hay Fever
[496] Nasal Polyps
[497] Night Sweats
[498] Post Nasal Drip
[499] Sneezing Spells
[500] Spits Up Blood
[501] Spits Up Phlegm
[502] Wheezes
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Mouth & Throat
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[400] Bad Breath
[401] Bitter taste in mouth in the morning
[402] Dry Mouth
[403] Excessive Saliva
[404] Sore or cracks in corners of mouth
[405] Glands often swell
[406] Frequent Canker Sores
[407] Frequent Fever Blisters
[408] Frequent Sore Throats
[409] Frequently has a sore tongue
[410] Sore Gums
[411] Swollen Gums
[412] Swollen Tongue
[413] Tongue Burns
[414] Tongue has grooves or fissures
[415] Tongue is coated
[416] Gums bleed when brushing teeth
[417] Toothaches
[418] Amalgam dental fillings
[419] Has had root canal(s)
[420] Other dental fillings (gold, composite, etc.)
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Endocrine
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[245] Coarse Hair
[246] Coarse Skin
[247] Diabetic
[248] Excessive Thirst
[249] Frequently feels cold
[250] Frequently feels hot
[251] Gets lightheaded when standing quickly
[252] Heals Slowly
[253] Unusually jumpy or nervous
[254] Unusually tired most of the time
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Cardiovascular
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[190] Cold Feet
[191] Cold Hands
[192] Experiences shortness of breath while standing still
[193] Heart skips beats
[194] Tendency of high blood pressure
[195] Leg cramps during bedtime
[196] Leg cramps during daytime
[197] Low blood pressure at times
[198] Pain in leg/ hip when walking
[199] Frequent Swollen Ankles
[200] Pains in the heart or chest
[201] Spells of rapid heart rate
[202] Troubled with blood clots
[203] Unusually slow pulse rate
[204] Varicose Veins
[205] Heart Palpitations
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Skin
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[520] Bruises Easily
[521] Excessive Perspiration
[522] Frequent Goosebumps
[523] Has Acne
[524] Has Psoriasis
[525] Hives
[526] Itchy Skin
[527] Problems with Eczema
[528] Has moles which are changing in size and/ or color
[529] Skin Eruptions
[530] Skin in rough, especially on back of the arms
[531] Skin is tender
[532] Sore that heals slowly
[533] Troubled with boils
[534] Dry Skin
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Ears
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[220] Discharge from ears
[221] Hard of hearing
[222] Punctured Eardrum
[223] Recurrent Ear Infection
[224] Ringing or noises in the ears
[225] Tinnitus
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Eyes
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[320] Bloodshot Eyes
[321] Blurred Vision
[322] Cross Eyes
[323] Eye Pain
[324] Eyes feel gritty
[325] Eyes Watery
[326] Mild Glaucoma
[327] Far Sighted
[328] Developing Cataracts
[329] Mild Macular Degeneration
[330] Itchy Eyes
[331] Near Sighted
[332] Dry Eyes
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Feet
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[350] Corns
[351] Frequent Foot Cramps
[352] Heel Spurs
[353] Painful Feet
[354] Plantar Warts
[355] Swelling in feet and/ or ankles
[356] Plantar Fasciitis
[357] Fungal Infection
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Neuromuscular
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[440] Bites Nails
[441] Frequent muscle soreness
[442] Muscle Spasms
[443] Muscle Weakness
[444] Tremors
[445] Frequent Headaches
[446] Often Dizzy
[447] Frequently feels faint
[448] Has Epilepsy
[449] Has Motion Sickness
[450] Has Osteoarthritis
[451] Has Rheumatism
[452] Rheumatoid Arthritis
[453] Joint stiffness in the morning
[454] Swollen Joints
[455] Leg pain at rest
[456] Spinal Curvature
[457] Low Back Pain
[458] Neck Pain
[459] Pain between the shoulders
[460] Shoulder/ Arm Pain
[461] Numbness/ tingling in the body
[462] Sleep Walks
[463] Stutters or Stammers
[464] Nerve Pain
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Behavior Patterns
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[150] Afraid to eat anywhere except home
[151] Always needs someone to advise
[152] Cries Often
[153] Difficulty Concentrating
[154] Difficulty Falling Asleep
[155] Difficulty Staying Asleep
[156] Easily Angered
[157] Feelings are hurt easily
[158] Frequently becomes scared for no reason
[159] Frequently miserable or blue
[160] Has to be on guard, even with friends
[161] Often annoyed by people
[162] Recurrent Bad Dreams
[163] Sometimes wishes to be dead or away from it all
[164] Upset by criticism
[165] Poor Memory
[166] Scared to be alone
[167] Strange people or places cause fear
[168] Under considerable emotional stress
[169] Unhappy when others are happy
[170] Brain Fog
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Urinary
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[555] Urinates more than 2 times per night
[556] Bed Wetting
[557] Blood in urine
[558] Difficulty starting urination
[559] Painful Urination
[560] Frequent Urination
[561] Troubled by urgent urination
[562] Incontinence when sneezing or laughing
[563] Loses bladder control
[564] Frequent Bladder Infections
[565] Frequent Kidney Infections
[566] Kidney Stones
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Men Only
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[585] Difficulty completing intercourse
[586] Difficulty getting or keeping an erection
[587] Discharge from the urethra
[588] Has had Vasectomy
[589] Had difficulty fathering children
[590] Lumps in testicles
[591] Painful Genitals
[592] Prostate Troubles
[593] Sores on External Genitalia
[594] Herpes
[595] Sexual Diseases
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Women Only
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Select all that apply:
[610] Heavy hair growth on face or body
[611] Cycles are every 27-29 days
[612] Abnormal cycle (>29 days and/or <26 days)
[613] PMS
[614] Menstrual Cramps
[615] Painful Periods
[616] Acne worse during menstruation
[617] Excessive Menstrual Flow
[618] Retains fluid during periods
[619] Premenstrual Depression
[620] Currently taking birth control medication
[621] Has taken birth control medication more than 1 year
[622] Has taken birth control medication within the last year
[623] Has had miscarriage
[624] Hot Flashes
[625] Takes hormone replacement medication
[627] Diminished sexual desire
[628] Painful Intercourse
[629] Poor or Infrequent Orgasm
[630] Lumps in the breasts
[631] Tender Breasts
[633] Vaginal Discharge
[634] Bloody Spotting Discharge
[635] Yeast Infections
[636] Sores on external genitalia
[637] Herpes
[638] Sexual Diseases
[639] Endometriosis
[640] Breast Reduction
[641] Breast Augmentation
[642] Abortion
[643] D&C
[644] Tubal Pregnancy
[645] Uterine Fibroids
[646] Ovarian Fibroids
[647] Breast Fibroids
[648] Currently Breastfeeding
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Environment
This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box.
Do you use:
Well Water
City Water
Do you use filtered water?
Yes
No
What kind of pipes are in your house?
Copper
Steel
CPVC
Pex
Other
What year was your house built?
Any home renovations in the past year?
Do you use chlorine bleach or other heavy duty cleaners in your home/ work?
Yes
No
Have you ever worked around heavy machinery, plumbing, automotive, or the metallurgic industry?
Yes
No
If yes, please explain:
Have you ever worked around industrial solvents, chemicals, or pesticides?
Yes
No
If yes, please explain:
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Medications
Please list all drugs you are currently taking on a daily basis.
Describe the name of the drug, what it is prescribed for, and how long you have been taking the drug.
Please list all drugs taken within the last year and/ or you take as needed, including over the counter drugs, antibiotics, aspirin, inhalers, etc.
Describe the name of the drug, what it is prescribed for, and how long you have been taking the drug.
Please list all vitamins/ herbs/ supplements you are taking on a regular basis.
Describe the name of the vitamin, the brand, and the dosage.
Please state your most significant concern.
Why are you visiting Dr. Banuelos' office?
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