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Health Screening Date

INDIVIDUAL HEALTH PROFILE

Case Number

PHIC No.

Last Name

First Name

Middle Name

Extension Name

Birth Date

Age

Sex

Client Type

REVIEW OF HEALTH SYSTEM

1. Chief Complaint (Please Describe)

2. Do you experience any of the following: Loss of Appetite, Lack of Sleep, unexplained weight Loss, feeling down/ depressed, fever, headache, memory loss, blurring of vision,or hearing loss?
Yes No

If YES pls explain

3. Do you experience any of the following: cough / colds, chest pain, palpitations, or difficulty in breathing?
Yes No

If YES pls explain

4. Do you experience any of the following: abdominal pain, vomiting, change in bowel movement, rectal bleeding or bloody / tarry stools?
Yes No

If YES pls explain

5. Do you experience any of the following: Frequent urination , frequent eating, frequent intake of fluids?
Yes No

If YES pls explain

6. For male and female, do you experience any of the following: pain or discomfort on urination, frequency of urination , dribbling of urine, pain during/after sex, blood in the urine, or foul-smelling genital discharge?
Yes No

If YES pls explain

7. For Females only

a.) Last Menstrual Period

b.) First Menstrual period

c.) Number of Pregnancy

8. Do you experience any of the following: Muscle spasm, tremors, weakness, muscle joint pain, stiffness, limitation of movement?
Yes No

If YES pls explain

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