FAMILY HISTORY						DO YOU SMOKE ?		Y     N
						# PACKS FOR HOW LONG		LONG?
REVIEW OF SYSTEMS   (CIRCLE  ALL  THAT				APPLY)
SKIN	CV	PULMONARY		GI	GU	MS	NEURO	CT
itching	chest pain	cough		difficult to	pain on	joint pain	headache	dry eyes
				swallow	urinating
swelling	palpitations	wheezing				joint	blurry	oral ulcers
				nausea	blood in	swelling	vision
red rash	swollen	short of			urine			dry mouth
	ankles	breath		vomiting		morning	light hurts
dry/flaky					kidney pain	stiffness	eye	tongue
	fainting	sleep		heartburn				swelling
burning		disturbed			testicular	limited	double
	severe			acid taste	pain	movement	vision	facial
blisters	dizziness	pain on		in mouth				swelling
		breathing			vaginal	muscle	ringing
ulcers	dizziness			diarrhea	discharge	pain	in ears	neck pain
	on standing	chest
		tightness		constipated		muscle	loss of	back pain
						weakness	hearing
								hand pain
							ear pain	in cold
FOR PHYSICIAN USE ONLY
HOME ENVIRONMENT		BASEMENT		DAMP?  Y   N         DEHUMIDIFIER?   Y        N
AGE OF HOME?		HOW HEATED?			FEATHERS?		BEDROOM FLOOR
					PILLOW     Y      N		W-W     Y       N
LOCATION (CIRCLE)					COMFORTER  Y   N		HARD WOOD
RURAL		A/C?	Y	N	AIR PURIFIERS?		Y           N
		CENTRAL?	Y	N	Y             N		AREA RUGS
URBAN		PORTABLE     Y             N			CENTRAL    Y     N		Y	N
		WHAT ROOM?			PORTABLE  Y    N		HOW OFTEN IS
SUBURBAN					WHERE?		BEDLINEN	WASHED
SMOKERS IN	HOUSE?	PETS?  WHAT KIND?    #
Y	N						HOT	WARM
							COLD