Medical History
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Medical History Questionnaire


Symptoms


Constitutional symptoms


Fever
Fatigue
Headaches
Weight gain

Eyes

Blurred Vision
Double vision
Blindness
Cataract
Pain


Ears, nose, mouth, throat

Hearing loss
Ringing ears
Congestion
Cavities
Soreness

Cardiovascular

Heart trouble
Chest pain or discomfort
Palpitation
Shortness of breath
Swelling of feet, ankles or hand

Gastrointestinal

Heartburn
Constipation
Rectal bleeding or blood in stool
Abdominal pain
Ulcer (stomach or duodenal)

Genitourinary (bladder)

Frequent urination
Burning
Painful urination
Blood in urine
Kidney stones

Musculoskeletal

Muscle pain
Joint pain
Stiff joints
Amputation
Cramps

Integumentary (skin )

Rash or itching
Ulcers
Lesions
Dryness
Mole changes
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