If you prefer, you can download a PDF version of this form
here.
Please complete this form before arriving for your appointment. Your data will be saved and sent securely to the MIRC staff. You will also be able to download a PDF version of the data once you have completed the form.
Please check Yes if you have ever had any of the following conditions
Please answer questions regarding family medical history
Please note if you have experienced any of these symptoms in the past 6 months.
Click on the symptom to note that you have experienced it. It will change color to indicate that you've selected it. Click it again to de-select it if necessary.
General |
Easily Fatigued |
Fatigued Only After Exercise |
Fatigued Upon Waking |
Excessive Weight Gain |
Excessive Weight Loss |
Night Sweats |
Fever |
Blood |
Anemia (Low Blood Count) |
Bleeding Disorders |
Taking Coumadin |
Easy Clotting |
Blood Clot |
DVT |
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Skin |
Bleeding |
Easily Bruising |
Sores |
Itching |
Fever |
Varicose Veins |
Non-healing Leg/Foot Wounds |
Glands |
Enlargment |
Pain |
Drainage |
Lymphoma |
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Eyes |
Glasses |
Cataracts |
Trauma |
Infection |
Temporary Blindness |
Visual Loss |
Glaucoma |
Ear |
Infection |
Loss of Hearing |
Pain |
Ringing in the Ears |
Ruptured Ear Drum |
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Nose |
Sinus Infection |
Nose Bleeds |
Runny Nose |
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Mouth/Throat |
Difficulty Chewing |
Excessive Tongue Movement |
Pain |
Dentures |
Frequent Sore Throat |
Hoarseness |
Pain or Difficulty Swallowing |
Neck |
Limitation of Movement |
Pain |
Stiffness |
Trauma |
Weakness |
Swelling |
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Respiratory |
Asthma |
Coughing |
Lung Infections |
Coughing Up Mucus |
Coughing Up Blood |
Shortness of Breath at Rest |
Shortness of Breath after Exertion |
Heart/CV |
Irregular Heart Beat |
Chest Pain |
Cold Hands and/or Feet |
Pain in Legs After Walking |
Palpitations |
Shortness of Breath |
Swelling of Hands and/or Feet |
GI |
Nauesa |
Indigestion |
Vomiting |
Abdomen in Pain |
Vomiting Blood |
Jaundice (Yellow Skin) |
Blood in Stool |
Genitourinary |
Change of Color in Urine |
Decreased Urination |
Painful Urination |
Frequent Urination at Night |
Increased Urination |
Change in Menstrual Cycle |
Erectile Dysfunction/Impotence |
Skeletal |
Generalized Weakness of Muscles |
Muscle Paralysis |
Decrease in Muscle Size |
Decrease in Muscle Strength |
Involuntary Movement |
Arthritis |
Joint Pain |
Neurological |
Dizziness |
Falls/Balance Difficulty |
Slurred Speech |
Severe Headaches |
Seizure |
Burning Pain / Numbness / Tingling |
Low Back Pain |
Psychiatric |
Memory Loss |
Difficulty Focusing |
Depression |
Mood Swings |
Sleep Disturbance |
Black Outs |
Light Headedness |
The following questionnaire is intended to help us better evaluate and treat your medical problems. We appreciate you filling it out in its entirety. Should you have any questions about what information to include, don't hesitate to ask the office staff.