Skin conditions? None Acne Color changes Itching Rashes Acne rosacea Eczema Lumps Scaling Dry skin Hives Moles Eye Conditions? None Eye Pain Glaucoma Double Vision Impaired Vision Dryness Nose and Sinus Conditions? None Frequent Colds Persistent Running Nose Bleeds Sinus Pain Polyps Stuffiness Mouth and Throat Conditions? None Bleeding gums Sore Tongue Ulcerations Frequent sore throat Endocrinological Conditions? None Hyperglycemia Hypoglycemia Goiter Hypothyroid Hyperthyroid Adrenal Gland Dysfunction Respiratory Conditions? None Asthma Pain with breathing Cough Difficulty breathing Wheezing Emphysema Pneumonia Shortness of breath Cardiovascular Conditions? None Angina Heart Disease Arrhythmia High Blood Pressure Murmurs Stent Placement Rheumatic Fever Dizziness Palpitations Ankle Swelling Bypass surgery Cardiomyopathy Pace maker Congestive Heart Failure Gastrointestinal Conditions? None GERDS Acid Reflux Recurring Diarrhea Irritable Bowel Syndrome Constipation Gall Bladder Problems Have you had a Upper GI Endoscopy? Have you had a Lower GI Endoscopy? Do You Have A History of Sexually Transmitted Disease?

Did any family member have a history of anemia?

What was the relation of the family member?

Urinary Conditions? None Frequency Incontinence Urgency Urinary Tract Infection Joints and Muscles Conditions? None Muscle pain /stiffness Arthritis Swelling of joints Weakness Muscle cramps Spacticity Muscle Wasting Decreased hand strength Hyperflexia Hyproflexia Circulatory conditions? None Coldness of hands/feet Numbness in hands/feet Deep leg pain Blood clots Varicose veins Anemia Neurological Circulatory conditions? (Current or Past) None Dizziness Memory Loss Numbness or tingling Seizures Fainting Paralysis Walking difficulties Speech problems Decreased sense of touch Headaches Restless leg syndrome Stroke Aneurysm Dementia Neuropathy Mental/Emotional Conditions? None Anxiety or nervousness Excessive fears Excessive anger Depression Tension/stress Hallucinations Delusions Sleep Conditions? None Sleep Apnea C-pap Do you take daytime naps? Energy Level? Normal Vitality Reduced Vitality Fatigue Chronic Fatigue Body Temperature Conditions? None Normal I get warm easily? I sweat easily? I get cold easily? Blood-borne Diseases Conditions? None Hepatitis A Hepatitis B Hepatitis C

Do you have balance Issues? Do You Require Assistance? None Walker Wheelchair Are you currently on Hospice? Do you require a caregiver full-time or part-time? Do you have someone who can accompany you during your treatment?