(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 |