Dr Susan Starr DC PC 2850 Johnson Ferry Rd.

Marietta, GA 770-518-8786

Patient Name____________________________________ Date ______________

Please describe the reason for your visit and what you hope to accomplish:____________
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PLEASE CHECK OFF THE FOLLOWING THAT APPLY TO YOU:

Digestive Track __swollen/discolored tongue/lips

__nausea & vomiting __canker sores
__diarrhea Heart __itching on roof of mouth
__constipation __irregular/skipped heartbeat __TOTAL
__bloated feeling __rapid/pounding heartbeat Nose
__stomach pains or cramps __chest pain __stuffy nose
__heart burn __TOTAL __chronically red/inflamed nose
__blood and/or mucous in stools __sinus problems
__TOTAL Joints & Muscles __hay fever
__pains/aches in joints __sneezing attacks
Ears __arthritis/osteoarthritis __excessive mucous formation
__itchy ears __stiffness/limited movement __TOTAL
__ear aches/ear infections __pain/aches in muscles
__drainage from ear __feeling weak/tired Skin
__ringing in ears __swollen/tender joints __acne
__hearing loss __growing pains in legs __itching
__reddening of ears __psoriatic/gouty arthritis __hives/rash/dry skin
__TOTAL __TOTAL __hair loss
__flushing/hot flashes
Emotions Lungs __TOTAL
__mood swings __chest congestion
__anxiety/fear/nervousness __asthma/bronchitis Weight
__anger/irritability/aggressiveness __shortness of breath __binge eating/drinking
__argumentative __difficulty breathing __craving certain foods
__frustrated/cries easily __persistent cough __excessive weight
__depression __wheezing __compulsive eating
__TOTAL __TOTAL __water retention
__TOTAL
Eyes Mind
__watery or itchy eyes __poor memory Other
__red/swollen/itchy eyelids __difficulty completing projects __frequent illness
__bags or dark circles under eyes __difficulty with mathematics __frequent/urgent urination
__blurred or tunnel vision __underachiever __genital itch/discharge
__TOTAL __poor/short attention span __anal itching
__confusion __TOTAL
Head __easily distracted
__headaches __difficulty making decisions Genitourinary
__faintness __learning disabilities __kidney
__dizziness __TOTAL __urinary tract
__insomnia/sleep disorder __bladder
__facial flushing Mouth & Throat Thrush __yeast infections
__TOTAL __chronic coughing
__gagging/clearing throat often
__sore throat/hoarse voice/voice loss
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