Patient Assesment Questionnaire

In order to insure you get the best results from the supplements that available from Drlynnmykel.com, I need to know a little more about your current state of health and medications you may currently be taking. All information is confidential.

Please fill out form, print and bring with you to your appointment.

First Name: Middle: Last:
Birth date: Gender: E-mail address:

General:

Chills Depression Dizziness Fainting Fever Forgetfullness Headache
Loss of Sleep Loss of Weight Nervousness Numbness Sweats Weight Gain

Women Only:

Breast Lump Nipple Discharge Hot Flashes Abdominal Pap Smear Vaginal Discharge Menstrual Cramps Spotting
Clotting with Menses PMS Currently Pregnant Irregular Periods Bleeding Between Periods Painful Intercourse

Age at first menses: Date of first period: Date of last PAP Smear:
Date of last breast exam: Date of last Mamogram: Number of Pregnancies:
Number of live Births: Number of living Children:
Children's Gender and Age:

Gastrointestinal:

Appetite Poor Bloating Bowel Changes Constipation diarhea Excessive Hunger Excessive Thirst
Gas Hemorhoids Indegestion Nausaea/ Vomiting Rectal Bleeding Vomiting Vomiting Blood

Eye, Ear, Nose, Throat:

Bleeding Gums Blurred Vision Crossed Eyes Difficulty Swallowing Double Vision Earache Ear Discharge Hay Feve Loss of Hearing Nosebleeds Persistent Cough Ringing in Ears Sinus Problems Vision - Flashes Vision - Halos

Cardiovascular:

Chest Pain High Blood Pressure Irregular Heart Beat Low Blood Pressure
Poor Circulation Rapid Heart Beat Swelling of Ankles Varicose Veins

Men Only:

Breast Lump Erection Difficulties Lump in Testicles Penis Discharge Sore on Penis Other

Skin:

Bruise Easily Hives Itching Change in Moles Rash Scars Sore that won't heal Psorisis

Muscle/Joint/Bone:

Arms Back Feet Hands Hips Legs Neck Shoulders

Genito-Urninary:

Blood in Urine Frequent Urination Lack of Bladder Control Painful Urination

Conditions:

Check Conditions you have or have had in the past...

AIDS Alcoholism Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorders Breast Lump Bronchitis Bulimia Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema
Epilepsy Gall Stones Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatitis Hernia
Herpes High Cholesterol HIV Positive Kidney Disease Liver Disease Measles Migraine Headaches
Miscarriage Mononucleosis Multiple Sclerosis Mumps Pacemaker Pancreatitis Pneumonia Polio
Prostrate Problems Psychiatric Care Rheumatic Fever Scarlet Fever Seizures Stroke Suicide Attempt
Thyroid Problems Tonsillitis Tuberculous Typhoid Fever Ulcers Vaginal Infection Venereal Disease
Other:

Medications: List what your are currently taking

Allergies to Medications or Substances:

FAMILY HISTORY Fill in the information regarding your family

Age:
State of Health: Cause of Death:
Age:
State of Health: Cause of Death:
Age:
State of Health: Cause of Death:
Age:
State of Health: Cause of Death:

Hospitalizations:

Year: Hospital:
Reason and Outcome:
Year: Hospital:
Reason and Outcome:
Year: Hospital:
Reason and Outcome:

Serious Illness or Injury

Year: Type of Injury or Illness:
Outcome:
Year: Type of Injury or Illness:
Outcome:
Year: Type of Injury or Illness:
Outcome: