(Please print out, circle appropriate symptoms, and fax to (301) 570-7989)
	NAME                                        DATE                   NUMBER
	
861 LOSING WEIGHT

862 GAINING WEIGHT

860 FEEL FATIGUED

215 FEEL VERY WEAK

825 SKIN ITCHES A LOT

704 THIRSTY ALL OF THE TIME

706 HUNGRY ALL OF THE TIME

344 SMOKE CIGARETTES LIKE A DUMMY

823 HANDS SHAKE AN AWFUL LOT

841 HAVE A LOT OF HICCOUGHS

910 DRINK A LOT OF BOOZE

853 SWEAT ("LIKE A PIG")

703 SOME KIND OF SKIN PROBLEM

762 AM HIV-POSITIVE

932 HAD MALIGNANT MELANOMA

931 HAVE A CHANGE IN A WART OR MOLE

14 GOING BALD IN PLACES

34 FACE GETS SUDDENLY FLUSHED

93 HAVE DOUBLE VISION SOMETIMES

117 DON'T SEE WELL TO THE SIDES

102 VISION GETS BLURRY AT TIMES

90 TOLD ABOUT CATARACTS

112 HAVE A HISTORY OF GLAUCOMA

91 HAVE HAD EYE SURGERY

125 HAVE PAIN IN MY EARS

136 MY EARS RING AND I GET DIZZY

161 HAVE MANY NOSEBLEEDS

202 HAVE SEVERAL CAVITIES

224 HAVE DIFFICULTY SWALLOWING

762 VOICE IS GETTING DEEPER

220 HAVE A SORE THROAT

252 HAVE STIFF-NECK

256 HAVE BEEN TOLD OF A GOITER

260 HAVE HAD NECK SURGERY

773 HAVE HAD THYROID SURGERY

771 HAD NECK IRRADIATION AS A CHILD

770 HAVE A THYROID NODULE

267 HAVE BURSITIS

377 HAVE LEG CRAMPS AT NIGHT

647 HAVE A HISTORY OF THE GOUT

649 TAKE A LOT OF ASPIRIN

658 HAVE VARICOSE VEINS

666 HAVE SWOLLEN LEGS

844 HAVE MANY JOINTS THAT ACHE

846 HAVE ONE JOINT THAT ACHES

661 MY LEGS HAVE SKIN PROBLEMS

293 FINGERS TINGLE AND GET NUMB

654 FEET TINGLE AND GET NUMB

642 HAVE PAIN IN THE HIPS

486 GOT AN ACHIN' BACK

310 HAVE A COUGH WITHOUT PHLEGM

314 COUGHIN' UP LOTS OF YELLOW STUFF

315 COUGHIN' UP BLOOD

316 PAIN IN THE MIDDLE OF MY CHEST

317 PAIN UNDER ONE BREAST

322 TIGHTNESS/PRESSURE IN MY CHEST

319 CHEST PAINS ARE SHARP

395 FAMILY HISTORY OF HEART ATTACKS

362 BEEN TOLD OF HIGH BLOOD PRESSURE

363 FAMILY HISTORY OF BLOOD PRESSURE

342 HAVE A HISTORY OF BRONCHITIS

345 GET SHORT OF BREATH ON EXERTION

325 GET CHEST PAINS ON EXERTION

374 FEEL MY HEART POUNDING OFTEN

378 GET CALF PAINS ON WALKING

385 HAVE HAD A HEART ATTACK

386 BEEN TOLD OF HEART MURMUR

390 HAVE HAD BLOOD CLOTS TO MY LUNGS

409 HAVE FREQUENT INDIGESTION

410 HAVE MANY BELLY PAINS

422 ANTACIDS HELP MY BELLY PAINS

434 FEEL NAUSEATED ALL THE TIME

433 GOT NAUSEOUS SUDDENLY

438 VOMIT ALL THE TIME

435 SUDDENLY STARTED VOMITING

449 BEEN TOLD OF DIVERTICULITIS

453 HAVE DIARRHEA ALL THE TIME

451 HAVE FREQUENT LOOSE STOOLS

452 DIARRHEA HIT SUDDENLY

463 TOLD OF HEMORRHOIDS

471 CONSTIPATED ALL THE TIME

501 HAVE HAD BLACK-TARRY STOOLS

502 STOOLS HAVE BEEN BLOOD-STREAKED

503 HAVE HAD BLOODY-MUCOUSY STOOLS

783 GO TO URINATE FREQUENTLY

785 IT BURNS WHEN I URINATE

591 HAVE HAD KIDNEY INFECTIONS

734 HISTORY OF KIDNEY STONES

529 HAVE HAD BLADDER INFECTIONS

789 BEEN TOLD OF PROTEIN IN MY URINE

526 CAN'T START MY URINE STREAM

527 BEEN TOLD OF A BIG PROSTATE

555 MY PERIODS ARE IRREGULAR

556 MY PERIODS ARE VERY PAINFUL

577 I TAKE BIRTH-CONTROL PILLS

576 I TAKE ESTROGENS

598 HAVE TROUBLE GETTING PREGNANT

569 HAVE TOO MUCH HAIR ON MY BODY

550 BEEN TOLD OF LUMPY BREAST

549 MILKY STUFF COMES FROM MY BREAST

807 HAVE HAD PITUITARY SURGERY

815 HAVE HAD A STROKE

810 HAVE HAD SOME DIZZINESS

808 HAVE HAD BRAIN SURGERY

817 MY MEMORY AIN'T WHAT IT WAS

1 HAVE HEADACHES IN MY FOREHEAD

2 HAVE HEADACHES ON ONE SIDE

3 HEAD ACHES IN THE NECK

4 HEAD ACHES IN THE TOP

5 HEADACHES IN VARIABLE SPOTS

259 BEEN TOLD OF CAROTID BRUITS

951 FEEL BLUE OR DEPRESSED

953 FEEL SUICIDAL AT TIMES

955 HAVE HAD A SHRINK TO HELP ME

960 HAVE HAD SEXUAL DIFFICULTIES

694 BEEN TOLD OF DIABETES