Clinical & Medical Questionnaire

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INTRODUCTION: CLINICAL VS MEDICAL: While there are many similarities, the key distinction is that medical treatment is intended to benefit and assist you while using accepted procedures and products, whereas clinical research is intended to learn about a medication in order to potentially assist patients in the future. This crucial distinction influences how the clinic monitors and follows up with patients. This distinction has an impact on both what you as a patient can expect from the clinic and what the clinic expects of you.

GOAL: The goal of this page is to bring to your attention anything that is happening to you that you are unable to remember or verbalize. Consider the list below as merely information or a way to verbalize.

ORGAN SYSTEMS: The main systems of the human body are:

Shak's CausalityCare.com | Human Body Systems

  1. Circulatory system / Cardiovascular system:
  • Circulates blood around the body via the heart, arteries and veins, delivering oxygen and nutrients to organs and cells and carrying their waste products away.
  • Keeps the body's temperature in a safe range.
  1. Digestive system and Excretory system:
  • System to absorb nutrients and remove waste via the gastrointestinal tract, including the mouth, esophagus, stomach and intestines.
  • Eliminates waste from the body.
  1. Endocrine system:
  • Influences the function of the body using hormones. Metabolism is the process by which the body changes food and drink into energy.
  1. Integumentary system / Exocrine system:
  • Skin, hair, nails, sweat and other exocrine glands
  1. Immune system and lymphatic system:
  • Defends the body against pathogens that may harm the body.
  • The system comprising a network of lymphatic vessels that carry a clear fluid called lymph.
  1. Muscular system:
  • Enables the body to move using muscles.
  1. Nervous system:
  • Collects and processes information from the senses via nerves and the brain and tells the muscles to contract to cause physical actions.
  1. Renal system / Urinary system
  • The system where the kidneys filter blood to produce urine, and get rid of waste.
  1. Reproductive system:
  • The reproductive organs required for the production of offspring.
  1. Respiratory system:
  • Brings air into and out of the lungs to absorb oxygen and remove carbon dioxide.
  1. Skeletal system:
  • Bones maintain the structure of the body and its organs.

CONDITIONS:

ALLERGY/IMMUNOLOGY
Low resistance to infection
Environmental allergies
Immune System Disorder

CANCER
Thyroid cancer
Bladder cancer
Breast cancer
Colon and rectal cancer
Endometrial cancer
Kidney (renal cell and renal pelvis) cancer
Leukemia (all bone marrow types)
Liver and intrahepatic bile duct cancer
Lung cancer (including bronchus)
Melanoma (skin)
Non-Hodgkin’s lymphoma
Pancreatic cancer
Prostate cancer
All other types of cancers

CARDIOVASCULAR
Chest pain or angina
Irregular heart rhythm (atrial fibrillation)
Swelling of the feet, ankles, hands
Blood Clotting Disorder
Carotid Artery Disorder
Congestive Heart Failure
Elevated Cholesterol
Heart Murmur
Heart Attack/Angina
Heart Surgery/Angioplasty
High Blood Pressure
Prosthetic/Artificial Heart Valve
Blockage of Arm or Leg Blood Vessels

CONSTITUTIONAL
Decreased general health lately
Recent weight changes
Extreme fatigue
Frequent nausea, vomiting
Difficulty sleeping

EARS, NOSE, MOUTH, THROAT
Change in hearing
Ringing in the ears
Recent nose bleeds
Chronic sinus problems
Voice changes

EYES
Wear glasses, contact lenses
Change in vision
Glaucoma

ENDOCRINE SYSTEM
Heat or cold intolerance
Excess thirst or urination
Diabetes (type 1, type 2, and gestational diabetes “diabetes while pregnant”)
Thyroid (hyperthyroidism, hypothyroidism)

GASTROINTESTINAL
Stomach Ulcers
Change in appetite
Severe heart burn
Vomiting blood
Frequent diarrhea
Constipation
Black or bloody stools
Abdominal pain
Liver Disease/Hepatitis
Kidney/Bladder Disease
Lung Disease
Tuberculosis

GENITOURINARY (urinary system)
Blood in urine  
Burning with urination  
Difficult/frequent urination  
Lack of bladder control  
Sexually transmitted disease  
Change in sexual function

HEMATOLOGY (lymphatic system)
Easy bruising
Frequent bleeding  
Enlarged lymph nodes

INTEGUMENTARY (Skin & Nail) & BREASTS
Unusual or prolonged rashes  
Breast pain or lump  
Change in hair or nails

MUSCULOSKELETAL
Joint/muscle stiffness or pain  
Weakness of muscles or joints
Neck
Shoulder
Elbow
Wrist
Back pain (Upper, Middle Lower)
Knee Pain
Ankle Pain
Difficulty walking
Difficulty Bending forward or backward

NEUROLOGICAL
Headaches  
Numbness/tingling sensation  
Weakness or paralysis  
Convulsions or seizures  
Change in memory/concentration  
Loss or blurring of vision or double vision
Black-outs/dizziness  
Memory loss or confusion
Other neurological problems

PSYCHIATRIC
Nervousness  
Depression  
Other

RESPIRATORY
Breathing problems/shortness of breath
Coughing up blood  
Chronic cough

OTHER
Alcohol Dependency
Toxic Exposure
Sexually Transmitted Disease