Woods & Water Medical Center

Rice Lake, WI

Questionnaire
Patient Name MHN DOB Age Gender

Review of Systems 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 troubles
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/Hemorroids Hair loss
Black bowel movements/melena Breast lumps/masses
Jaundice/Liver trouble Numbness/Tingling
Coordination/Balance changes/mobility Memory/Concentration
changes 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
periods
Post-menopausal Hot flashes
Contraception Estrogen replacement
Breast feeding

Month and year of __________________ Month and year of last ______________________

mammogram
Start date of last period
Number of pregnancies
_ pap
__________________ Age at first period ______________________
_
__________________ Number of children born ______________________
_ alive