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5333 McAuley Drive
Reichert Health Building
Suite 5115
Ypsilanti, MI 48197
734.434.4430
www.annarborendo.com
PATIENT INFORMATION
Name*
Currently Using Insulin Pump/Dexcom/Libre?*

YesNo
Preferred Pharmacy/City/Street*
Select the checkbox if you have recently experienced any of the following symptoms, otherwise leave blank
General/Constitutional

FeverWeight gainWeight loss
Ophthalmologic/Eyes

Blurred visionEye pain
ENT (Ear/Nose/Throat)

Difficulty swallowingSore throat
Endocrine

History of radiation to the head or neckCold intoleranceExcessive thirstHeat in tolerance
Respiratory

Shortness of breathCoughWheezing
Cardiovascular

Chest painDizziness on standingFluid accumulation in legsPalpitations
Gastrointestinal

Abdominal painConstipationDiarrheaHeartburnNauseaVomiting
Hematology/Blood

Easy bruisingProlonged bleeding
Women

Decline in sexual desireHeavy bleeding during mensesHot flashesIrregular mensesMissed periods
Men

Low sex driveErection problems
Genitourinary

Frequent urinationPainful urination
Musculoskeletal

Muscle achesPainful joints
Podiatric/Feet

Foot numbnessFoot pain
Skin

HivesRash
Neurologic

HeadacheTremor
Psychiatric

AnxietyDepressed mood
Additional Comments:
Should be Empty: