New Patient Medical History Form | Page 5

Genitourinary:
� Urinary frequency / urgency
� Nighttime urination
Musculoskeletal: � Back pain( upper)
� Back pain( lower) � Muscle aches / pain
� Joint pain
Integumentary:
� Acne
� Rash
� Skin breakdown
Neurological: � Dizziness
� Headaches
� Weakness / low energy
� Seizures
� Fainting / Syncopal episodes Psychiatric: � Anxiety
� Depression
� Insomnia
� Hyperactivity
� Inability to concentrate
� Nervousness
� Mood changes
� Inattention
Endocrine: � Excessive thirst
� Cold intolerance
� Excessive sweating
� Hair changes
� Heat intolerance Immunologic: � Fatigue / tiredness
� Bruising
Comments: _________________________________________________________________________
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Patient Label Page 5 of 5
Form Number: 530-206 Revision Date: 7 / 2024