Sara Hunt - Priority Health
Priority Fitness & Health - Waukee, IA
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GENERAL
(Please check)

__ Headaches
__ Insomnia (loss of sleep)
__ Loss of weight
__ Dizziness
__ Fainting spells
__ History of seizures
__ Fatigue
__ Depression
__ Enlarged thyroid
__ Double/blurred vision
__ Other

MUSCLE AND JOINT
(Please check)
__ Arthritis
__ Bursitis
__ Low back pain
__ Neck pain
__ Other pain
__ Swollen joints

GENITO – URINARY
(Please check)
__ Kidney Infection or stone
__ Painful urination
__ Prostate trouble
__ Kidney Failure

GASTRO INTERTINIAL
(Please check)

__ Colitis
__ Constipation
__ Crohn’s Disease
__ Ulcerative Colitis
__ Diverticulitis
__ Diverticulosis
__ Gall Bladder Disease
__ Hemorrhoids
__ Fissures/Fistulas
__ Liver trouble
__ Cirrhosis
__ Rectal bleeding
__ Vomiting of blood
__ Cancer
__ Family History-Colon cancer


CARDIOVASCULAR
(Please check)
__ High blood pressure
__ Hardening of the arteries
__ Angina (chest pain)
__ Poor circulation
__ Rapid heart beat
__ Irregular heart heat
__ Congestive heart failure
__ Swelling of ankles



WOMEN
(Please check)
__ Painful menstruation
Last menstrual period _______
(date)
__ Vaginal discharge
__ Breast pain
Are you pregnant?  Yes/No                                                                                                                                                                                                                                                                                                                                                                                                   
RESPIRATORY
(Please check)

__ Shortness of breath
__ Chronic cough
__ Vomiting blood
__ Emphysema
__ Bronchitis
__ Asthma (wheezing)

SKIN
(Please check)
__ Bruise easily
__ Dryness
__ Itching
__ Rash




Priority Fitness