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GENERAL % Chills % Depression % Dizziness % Fainting % Fever % Forgetfulness % Headache % Loss of sleep % Loss of weight % Nervousness % Numbness % Sweats MUSCLE/JOINT/BONE Pain, weakness, numbness: % Arms % Hips % Back % Legs % Feet % Neck % Hands % Shoulders GENITO-URINARY % Blood in urine % Frequent urination % Lack of bladder control % Painful urination GASTROINTESTINAL % Appetite poor % Bloating % Bowel changes % Constipation % Diarrhea % Excessive hunger % Excessive thirst % Gas % Hemorrhoids % Indigestion % Nausea % Rectal bleeding % Stomach pain % Vomiting % Vomiting blood CARDIOVASCULAR % Chest pain % High blood pressure % Irregular heart beat % Low blood pressure % Poor circulation % Rapid heart beat % Swelling of ankles % Varicose veins EYE, EAR, NOSE, THROAT % Bleeding gums % Blurred vision % Crossed eyes % Difficulty swallowing % Double vision % Earache % Ear discharge % Hay fever % Hoarseness % Loss of hearing % Nosebleeds % Persistent cough % Ringing in ears % Sinus problems % Vision - Flashes % Vision  Halos SKIN % Bruise easily % Hives % Itching % Change in moles % Rash % Scars % Sore that won t heal MEN ONLY % Breast lump % Erection difficulties % Lump in testicles % Penis discharge % Sore on penis % Other WOMEN ONLY % Abnormal Pap Smear % Bleeding between periods % Breast lump % Extreme menstrual pain % Hot flashes % Nipple discharge % Painful intercourse % Vaginal discharge % Other Date of last menstrual period_____________ Are you pregnant?___ # of children?_______    & ( L | * H  ɹzogz^X^gzgozgzgo hRWCJh GhRWCJhRWCJaJh GhRWCJaJh GhRW5CJaJhRW5CJaJhRWh GhRW5 jh GhRW h GhRWhRW5:OJQJaJh GhRW5:OJQJaJhRW5CJaJhC$5CJaJhC$hC$5CJaJhPI5CJaJhPIhC$5:OJQJaJgh  [kd$$IflLD%%  t 0%644 l` ap ytQ$IfgdRWl$a$gdC$$a$gdC$~3    . F \ l  ( L * H j $IfgdRWl$$Ifa$gdRWl  4 J j .@d Nx$$Ifa$gdRWl$IfgdRWl@`$<Vz&HRr$$Ifa$gdRWl$IfgdRWl>@HRL(((((&(((((())*l,n,..ƻƻڲϪϚwokϲhRWh GhRW5 jh GhRW h GhRW hRW5hRW5:OJQJaJh GhRW5:OJQJaJU hRWCJh GhRWCJhRW5>*CJaJhRW5CJaJh GhRWCJaJhRWCJaJh GhRW5CJaJh GhRW5CJ hRW5CJ"6f"Xt<LN$$Ifa$gdRWl$IfgdRWlN((Hkd$$Ifl\LHD% Z Z   t0%644 laytQ$IfgdRWlConditions Check (() conditions you have or have had in the past.% AIDS % Alcoholism % Anemia % Anorexia % Appendicitis % Arthritis % Asthma % Bleeding Disorders % Breast Lump % Bronchitis % Bulimia % Cancer % Cataracts% Chemical Dependency % Chicken Pox % Diabetes % Emphysema % Epilepsy % Glaucoma % Goiter % Gonorrhea % Gout % Heart Disease % Hepatitis % Hernia % Herpes% High Cholesterol % HIV Positive % Kidney Disease % Liver Disease % Measles % Migraine Headaches % Miscarriage % Mononucleosis % Multiple Sclerosis % Mumps % Pacemaker % Pneumonia % Polio% Prostate Problem % Psychiatric Care % Rheumatic Fever % Scarlet Fever % Stroke % Suicide Attempt % Thyroid Problems % Tonsillitis % Tuberculosis % Typhoid Fever % Ulcers % Vaginal Infections % Venereal DiseaseCurrent Medications HEALTH HISTORY Allergies (to medications or substances)Family HistoryFamily history of premature heart disease? 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