18. Indicate if you have any immediate family members with any of the following:
__ Rheumatoid Arthritis	__ Diabetes                             __ Lupus
__ Heart Problems                                                  __ Cancer                                __ ALS
19. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column.
.

     Present    

 __Diabetes
  __Excessive Thirst            __Frequent Urination   __Smoking/Tobacco Use
  __Drug/Alcohol Dependance
          __Allergies          
        __Depression 
       __ Systemic Lupus 
         __ Epilepsy
 __Dermatitis/Eczema/Rash            __    HIV/AIDS
   For Females Only
        __Birth Control Pills
  __HormonalReplacement Replacement
d Pregnancy
Past Present                                   Past
__	__ Headaches	__
__	__ Neck Pain	_
___  __ Upper Back Pain	_
__       __ Mid Back Pain	_
__	__ Low Back Pain	__
__	__ Shoulder Pain	__
__	__ Elbow/Upper Arm Pain         __
__	__ Wrist Pain	__
__	__ Hand Pain	__
__	__ Hip Pain	__
__	__Upper Leg Pain	__
__	__ Knee Pain	__
__	__ Ankle/Foot Pain	__
__	__ Jaw Paina                             __         
__	__ Joint Pain/Stiffness	__
__	__ Arthritis	__
__	__ Rheumatoid Arthritis	__
__	__ Cancer                                 __
__	__ Tumor	__
__	__ Asthma	__
__	__Chronic Sinusitis	__
__	__ Other:      __________

Present                             past                                     
__High Blood Pressure      
__Heart Attack	__
__Chest Pains                       __                
__Stroke                                __
__ Angina                            __
__Kidney Stones                   __
__Kidney Disorders               __
__ Bladder Infection              __
__ Painful Urination               __
__Loss of Bladder Control     __
__ Prostate Problems            __
__ Abnormal Weight Gain/Loss
__ Loss of Appetite                __
__Abdominal Pain             
__ Ulcer                                
__Hepatitis                            __
__ Liver/Gall Bladder Disorder__
__ General Fatigue
__ Muscular ^coordination
__ Visual Disturbances
__ Dizziness

20. List all prescription medications you are currently taking:
21. List all of the over-the-counter medications you are currently taking:
22. List all surgical procedures you have had:
23. What activities do you do at work?
 __Sit:                                __ Most of the day    
 __ Stand:                          __Most of the day 
 __Computer work:          __ Most of the day                __ on the phone:              __ Most of the day
  	
 __ Half the day a
 __Half the day
 __ Half the day 
 __ Half of the day
	
 __ A little of the day 
 __ little of the day 
 __A little of the day  
 __A little of the day
	
24. What activities do you do outside of work?

 

__ No       __ Yes
25. Have you ever been hospitalized?
if yes, why __________________
26. Have you had significant past trauma?     __ No        __ Yes
27. Anything else pertinent to your visit today?___________

Patient Signature_________________________   Date:____________