| Michigan Hyperhidrosis/DRY BODY Questionaire (248) 381-4600 Name: Telephone Address: Home: Cell: Work: Email: Fax: Contact Person: Insurance Information: How did you learn about our services? ***Please provide a copy of the front and back of your insurance card What are you symptoms? What part of the body is affected? How have you treated this problem? Do you have any other medical problems? Have you ever had chest surgery? Do you take blood thinners? Do you have any allergies? What is your height? Weight? List any medications? Do you have a latex allergy? Excessive sweating can occasionally be related to other diseases including hyperthyroidism or other endocrine diseases, severe psychiatric disorders, obesity, menopause and brain tumors. Please mark and comment about any of the symptoms or conditions you may have: |
| Neurological: ____Headaches ____Dizziness/vertigo ____Fainting/LOC ____Seizures ____Tremor/movement disorder ____Tic ____Memory impairment ____Impaired cognition ____Motor impairment (inc. gait) ____Paresis ____Paralysis ____Impaired speech/dysphasia, aphasia ____Numbness or tingling ____gait or walking problems ____Vision problems ____History neurological problems ____Stroke ____Seizure disorder ____Dementia |
Endocrine/Metabolic: ____Weight loss/gain ____Heat/cold/intolerance ____Weakness/fatigue ____Nervousness/irritability ____Palpitations/tachycardia ____Hypertension ____ Sleep changes ____Excess urination ____Change in urinary frequency ____Excessive thirst ____Vision changes ____Changes in skin color ____Changes in bowel movements ____Changes in hair and hair distribution ____Abnormal nipple discharge ____Menstrual changes ____Pattern/severity of bleeding ____Pregnant? ____Impotence ____Libido ____Thyroid problems ____Brain Tumor |
Respiratory: ____Shortness of Breath ____Cough ____Coughing blood ____Excessive Sputum ____Chest pain ____Upper respiratory problems ____Sore throat ____Rhinorrhea/nasal congestion ____Ear congestion ____Any pulmonary disease ____COPD, emphysema ____Asthma ____Recurrent pulmonary ____infections/pneumonia ____Cystic fibrosis ____TB or TB exposure ____Occupational pulmonary exposures ____Smoking history ____ How long? ____ How many each day ____ NONE of the Neurological, Endocrine/Metabolic, Respiratory or Infectious symptoms or conditions apply to me |