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Patient Center
Dr. Jeff
FAQ
Contact
814-235-2266
Home
Patient Center
Dr. Jeff
FAQ
Contact
814-235-2266
Patient Health Questionnaire
Patient Name
Please check any that you currently have or have previously expeienced
Alcoholism
Allergies
Anemia
Arteriosclerosis
Arthritis
Asthma
Cancer
Cold Sores
Constipation
Convulsions
Depression
Diabetes
Diarrhea
Dizziness
Eczema
Epilepsy
Gallbladder Problems
Gout
Headaches
Heart Attack
Heart Disease
High Blood Pressure
Irregular Periods
Jaw Pain
Low Blood Pressure
Low Blood Sugar
Menstrual Cramps
Migraines
Multiple Sclerosis
Nervousness
Neuritis
Pain - Neck
Pain - Mid Back
Pain - Low Back
Pain - Arm/Elbow
Pain - Hand
Pain - Wrist
Pain - Shoulder
Pain - Ankle or Foot
Pain - Leg
Pain - Knee
PMS
Pregnancies
Ringing in Ears
Scoliosis
Sinus Infection
Stroke
Swelling, Stiffness of Joints
Thyroid Problems
Tiredness/Fatigue
Ulcers
Vision Disturbances
Walking Problems
Other
Other (please describe)
Height
Weight
Are you a smoker?
Yes
No
Number of packs per day
Do you drink alcohol?
Yes
No
Number of drinks per week
Coffee/Caffeine drinks per day?
Alcohol Dependence?
Yes
No
Drug Dependance?
Yes
No
A family member has had: (choose all that apply)
Alcoholism
Cancer
Chronic Headaches
Chronic Back Problems
Diabetes
Epilepsy
Heart Problems
High Blood Pressure
Lupus
Lung Problems
Rheumatoid Arthritis
Other
Other (please describe)
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