Woods and Water Medical Center

Rice Lake, WI

Questionnaire
Patient name MHN DOB Age Gender

Review of Symptoms Yes Yes

Frequent/Severe headaches/Migraines Burning/other difficulty urinating
Ear aches/drainage Bladder/Kidney infection/sepsis
Frequent bloody noses Kidney stones/nephroliths
Difficulty swallowing Convulsions/Seizures
Hoarseness Fainting spells/dizziness
Shortness of breath Joint pain/arthritis/gout
Persistent cough Back trouble
Chest pain Nervousness
Heart disease/murmur Depression
Hypertension Family/Sexual problems
Insomnia Unusual fatigue/weakness/lethargy
Swelling legs/ankles/edema Weight loss
Palpitations/irregular heart beat Skin rashes
Abdominal/stomach pain/indigestion Vision changes/loss
Nausea Hearing loss/ringing in ears/tinnitus
Vomiting Lumps/Knots/Swelling
Diarrhea Unusual bruising/bleeding
Constipation Heat/Cold intolerance
Rectal bleeding/hemorrhoids Hair loss
Black bowel movements/melena Breast lumps/masses
Jaundice/Liver trouble Numbness/Tingling
Coordination/Balance changes/mobility changes Memory/Concentration changes/dementia
Difficulty bathing/dressing Nose dry/congested
Frequent nighttime urination/nocturia

Gynecological History Yes Yes

Taking birth control pills Bleeding between menstrual periods
Excessive vaginal discharge Excessive bleeding during menstrual period
Post-menopausal Hot flashes
Contraception Estrogen replacement
Breast feeding
Month and year of mammogram Month and year of last pap
Start date of last period Age at first period
Number of Pregnancies Number of children born alive