Gas (flatus)? Rectum?Women: Vaginal Problems? Problem with menstrual flow.Frequency? Menstruation heavy? Light?Contraception use? STD?Men: GenitalTesticular Exam: Prostate:(PSA/PAP)OINTS: Arms: _____ Shoulder: _____ Legs Feet?ADDITIONAL PROBLEMS:___________ III. LIFESTYLEStressStress in your life?Your stress level? Scale of 1 - 10?JoyWhat gives you joy in life?What gives you pleasure in life?Do you have hobbies you enjoy?Do you live alone or with family/friends?Your joy level? 1 - 10?SleepAny difficulty with sleep? Hours do you sleep?Do you awaken refreshed after sleeping?IV. FAMILY HISTORY
Significant Family History of Illness:
MOTHER: Alive:_____ Age:FATHER: Alive _____Age:SIBLINGS: Health: Age:Parents: Smokers?Alcohol or drug use in the family?History of congenital diseases in the family?Where are you in the birth order?What was the environment like as a child? Peaceful? Happy? Tension? Conflicted?Birth: Any unusual problems at birth? Premature? Other?