Please circle any of the following which have been a problem in the past month.

Category

Issues

None

General

weakness, fatigue, fever, sweats, weight loss, weight gain, appetite change, thirst change, hot or cold intolerance, pain

Skin

itching, rash, mole change

Eyes

vision change, cataracts, glaucoma

Ears, nose, mouth

dizziness, ringing in ears, hoarseness, sore throat, nose bleed, sinus infection, dental problems

Breasts

discharge, mass, pain, tenderness

Lungs

cough, shortness of breath, chest pain with breathing, coughing blood, wheezing

Heart

chest pain, irregular heart beat, fainting episodes, ankle swelling, leg pains, need more than one pillow to sleep

GI

abdominal pain, nausea, vomiting, diarrhea, constipation, jaundice, black stools, blood in stools, difficulty swallowing, hemorrhoids

Genitourinary

painful urination, frequent urination; urgent urination; blood in urine, kidney stones, urinating at night

Musculo-skeletal

arthritis, stiffness, swelling, weakness, backache, cramps

Nervous system

headache, seizure, dizziness, tremors, memory loss, paralysis, numbness, tingling, muscle weakness

Mental health

anxiety, depression, personality change, suicidal thoughts, anger control problems, alcohol or drug problems, other

Male reproductive

testicular pain, swelling, sexual difficulty

Female reproductive

pelvic pain, loss of period, abnormal bleeding, sexual difficulty hot flashes, vaginal dryness

Hematologic

bruising, bleeding, repeated infections

Lymph nodes

swelling, tenderness

Other issues you would like to discuss:

If you are unsure about any terms, simply circle the category and we will discuss it with you.