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Patient Health Form

Are you experiencing any of these symptoms?

Systemic Symptoms

Weight Change:
YesNo
Chills
YesNo
Fever
YesNo
Night Sweats
YesNo
Feeling tired
YesNo

Eyes, Ears, Nose, Throat

Hearing loss
YesNo
Ringing ears
YesNo
Eye disease
YesNo
Blurred Vision/double vision
YesNo
Glaucoma
YesNo
Mouth sores
YesNo
Bleeding gums
YesNo
Swollen neck glands
YesNo

Pulmonary Symptoms

Shortness of breath
YesNo
Cough
YesNo
Coughing up blood
YesNo
Night Sweats
YesNo
Wheezing
YesNo

Heart

Chest pains
YesNo
Fast heart rate
YesNo
Palpitations
YesNo
Swelling of feet, ankles, hands
YesNo

Gastrointestinal Symptoms

Difficulty Swallowing
YesNo
Heartburn
YesNo
Nausea
YesNo
Vomiting
YesNo
Abdominal pain
YesNo
Diarrhea
YesNo
Blood in stool
YesNo
Painful bowel movements/constipation
YesNo
Change in appetite
YesNo

Skin Symptoms

Pruritus
YesNo
Skin lesions
YesNo
Rashes
YesNo

Hematological Symptoms

Easy Bleeding Easily bruise
YesNo

Endocrine Symptoms

Excessive sweating
YesNo
Excessive thirst
YesNo
Glandular/hormone problems
YesNo
Thyroid Problems
YesNo
Diabetes
YesNo
Dry skin
YesNo

Neurological Symptoms

Dizziness
YesNo
Vertigo
YesNo
Frequent headaches
YesNo
Convulsion or seizures
YesNo
Numbness and Tingling
YesNo
Tremors
YesNo
Paralysis
YesNo
Stroke
YesNo
Head Injury
YesNo

Psychiatric

Memory Loss or confusion
YesNo
Anxiety
YesNo
Depression
YesNo
Nervousness
YesNo
Sleep disturbances
YesNo

Musculoskeletal

Joint pain
YesNo
Joint stiffness/swelling
YesNo
Back pain
YesNo
Weakness of muscles/joints
YesNo
Neck Pain
YesNo

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