laintegrativegi.com - Symptom History Form

SYMPTOM HISTORY FORM
Patient Name: *
Date of Birth*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Please select the symptoms that you experience.

Digestive Symptom

	Absent (0)	Present (1)
Abdominal Pain
Acid Reflux
Acidic Stomach
Altered Bowel Habits
Bloating
Burping/Belching
Constipation
Dark Urine
Diarrhea
Difficulty Swallowing
Feeding Difficulties
Flatus/Wind/Excess Gas
Food Intolerance
Heartburn
Indigestion
Irregular Bowel movements
Lack of Appetite
Nausea
Need for Laxatives
Pain during bowel movement
Rectal Bleeding
Vomiting
Weight Gain
Weight Loss

Digestive Symptom Total
Range of digestive symptoms score: 0 – 24

Your Score: {digestiveSymptom8}
Non-digestive Symptom

General

	Absent (0)	Present (1)
Persistent/Recurrent Fever
Fatigue/Malaise
Night Sweats

Eyes

	Absent (0)	Present (1)
Trouble Seeing
Eye Pain
Inflamed Eyes
Double Vision

Ears

	Absent (0)	Present (1)
Loss of Hearing
Ringing in the Ears
Discharge

Nose

	Absent (0)	Present (1)
Loss of Smell
Frequent Colds
Obstructions
Excess Discharge
Nosebleeds

Mouth

	Absent (0)	Present (1)
Sore or Bleeding Gums
Soreness of Tongue
Toothache

Throat

	Absent (0)	Present (1)
Postnasal Drip
Soreness
Hoarseness

Breasts

	Absent (0)	Present (1)
Lumps
Discharge

Nervous System

	Absent (0)	Present (1)
Anxiety
Headaches
Dizziness
Fainting
Convulsions or Seizures
Nervousness
Sleeplessness
Depression
Change in Sensation
Memory Loss
Poor Coordination
Weakness or Paralysis
Brain Fog

Cardio Respiratory Systems

	Absent (0)	Present (1)
Cough Persisting
Sputum (Phlegm)
Bloody Sputum
Wheezing
Chest Pain or Discomfort
Pain on Breathing
Difficulty Breathing while lying down
Swelling of Ankles
Bluish Finger or Lips
High Blood Pressure
Palpitations

Locomotor

	Absent (0)	Present (1)
Muscle Cramps
Muscle Weakness
Pain in Joints
Swollen Joints
Deformity of Joints
Back Pain
Stiffness

Skin

	Absent (0)	Present (1)
Eruptions (Rash)
Change in Color
Change in Hair
Change in Nails

Genitourinary System

	Absent (0)	Present (1)
Increase in Frequency of Urination Day/Night
Feel Need to Urinate Without Much Urine
Unable to Hold Urine
Pain or burning
Blood in Urine
Impotence
Lack of Sex Drive
Pain with Intercourse

Total Non-digestive symptoms
Range of non-digestive symptoms score: 0 – 66

Total Score: {totalNondigestive}
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