SSA Detailed History Form - PDF Document

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SSA Detailed History Form

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  1. SSA Detailed History Form Patient Name: ___________________________ Date: ___________ Constistanly taking supplements ________% Instructions: For any that applies to you, please mark on a scale from 0-10, 10 being the worse Headaches Sinus Heart Hemorrhoids Basal Temples Cluster Crown TMJ Frontal Migraine -prodromal-halluc -Photophobia -Olfaction -Nausea Other Dry Drain Plug Post -white, yellow, green, gray -brown, blood, clear Sneezing Smell loss Taste loss Thirst Other_____________ Sharp heart pain Palpitations MVP Tachy Nausea/ Queasy Brady Arm Pain Other_____________ Swollen Burning Blood Distended Itchy Stingy Achy Prostrate Breathing History/Current Burn ache pain restrict dribble em ission swell Other________________ Shortness of breath Constant Exertion Asthma Wheeze Air hunger Yawning Other_____________ Mouth Ears Sore throat Hoarsenesss Cough (dry/productive) Allergies URI Fever Chills Halitosis Cankers Blisters Flu Other_____________ Creases R L Noise (Ring/Hiss/Pound) Plug Pop Ache Drain Itch Hearing Loss Dizzy Wax Other______________ Stomach Vagina Burn Itch Dry Pain Blood Discharge -clear/white/green/green/brown Dischare Other________________ Heartburn Indigestion -Aches/Cramps/Nausea/Queasy Bloat Belch Gas Ulcer Hiatal Hernia Other_____________ Eyes Neck Burn Tear Ache Red Dry Film Blur Floaters Spots Tired Puffy Stye Twitch Cirlces Other______________ Stifness Shoulder tension Chielosis Dry mouth Cold hands/feet Sweaty hands/feet Gums Teeth Glands Dysphagia Other_____________ Fecal Consistency Color feces: light or dark Normal Soft Hard Pebbles Dry Ribbon-like Mucous Diarrhea Constipation Other______________ Ovulation Pains Cysts Discharge Regulat Irregular Fibroids Other________________ Chest Breast Tenderness Breast feeding Fibrosis Lum p Discharge Prothesis Reduction Tender Other________________ Tension Tight Pressure Heavy Anxiety Congestion Pain Sternal Other_____________ Tongue Bowel Cracks Patches Red Spots Swollen Color Veins Frenular Cyst Coated pH Other_____________ Regular Incomplete Sluggish every___days Cramps Laxative/Suppositories/Softners Enemas/Colonics/Bulk Other______________ SSA Detailed History Form - continued Doctor ONLY Menopause Nails Appetite Natural Spots Low

  2. Surgical (partial/com plete) Horm ones Patch Flashes Form ication Luna Weak Ridges Lines Other_______________ High Sweet Salt Coffee Tea Chocolate Beer Wine Starch Spices Ice Cream Soda Other_______________ Weight (+/-_______________lbs) Overall weight loss (+/-_____lbs) RJL: ___________________ Height ___________ BF% ________________ Pulse_______________ BP: _____/_____ Supine BP: _____/_____ Standing Blood Oxygen _______________ Chol. ________ Trig: ________ HDL: _______ pH: _________ Tissue Calcium : ______ Moist sense: ________ Menses Urination Regular Irregular (early/late) _________ LMP BC Pill Flow Heavy Moderate Light Long Brief Cram ps Mild Moderate Severe Back Lower Abdom inal Puffines Face swelling Hands swelling Feet swelling Body swelling Breast Tenderness Acne (pre/m id/post) Spotting Clots PMS (m ood/Irritable/depression) Other________________ Nocturnal ____Night _____Week Frequency Urgent Burn Pain Odor Spam Leak UTI Other_______________ Misc. Stress Slow healing Bruising Arthrits______________ Coordination Concentration Nutritional Exam Liver HCL Pancreas Enzym e Murphy's sign Right thum b web Right thenar pad Large Intestines Sm all Intestines Navel Adrenal/groin ITB Sleep Difficulty falling asleep Insom nia Interrupted ____/night Sleep cravings Jolts Dream s Night sweats Restlessness Hrs. per night ________ Other_______________ Energy Low Variable Up Slow to start Im prove with m eals Worse with m eals Im prove in afternoon Worse in afternoon Exercise _________________ Other_____________________ Emotions Measurements Sad Grief Depression Moody Irritable Worry Angry Nervous Frustrated Anxiety Panic Cry Fear Sham e Other_______________ Biceps _____________ Chest ______________ Waist ______________ Hips_______________ Thigs______________ Muscles Cram ps Aches Anxiety -legs/feet/arm s/legs Other________________ Memory Nam e Num ber Word Other_______________ Medications 1)_________________________ 2)_________________________ 3)_________________________ 4)_________________________ 5)_________________________ Skin Sexuality Flat Low Norm al ED Orgasm Other_______________ Rash Acne Dry Itch Fungus Patch Fluid Cellulite Other_______________ Allergies/Surgeries 1)_________________________ 2)_________________________ 3)_________________________ 4)_________________________ 5)_________________________