Please list any problems you are currently having.
For those who are generally healthy, these will likely be left blank:
General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain) |
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Ear, Nose, Throat (e.g., sinus congestion, dry mouth/throat, sleep apnea, hearing problems) |
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Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIA/stroke) |
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Respiratory (e.g., chronic cough, shortness of breath, wheezing) |
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Genital, Kidney, Bladder (e.g., urinary problems, discharge, menstrual changes, impotence) |
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Gastrointestinal (e.g., constipation, diarrhea, heartburn (GERD), jaundice, nausea, vomiting) |
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Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination) |
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Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements) |
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Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration) |
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Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, speech problems) |
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Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive) |
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Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising) |
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Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes) |
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