HEAD AND NECK

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					Please mark the appropriate squares in the following list of symptoms. If you have had a symptom in the PAST and do not have it now, check the box like this: If you are having the symptom CURRENTLY, fill in the box like this:

HEAD AND NECK □ Dizziness □ Fainting □ Neck stiffness □ Enlarged lymph glands □ Headaches □ Other ______________ EARS □ Infection □ Pain □ Ringing □ Decreased hearing □ Other______________ EYES □ Blurred vision □ Visual changes □ Spots □ Inflammation □ Glasses/contacts □ Other______________ NOSE, THROAT, & MOUTH □ Nose bleeds □ Sinus infection □ Hay fever or allergies □ Recurring sore throat □ Hoarseness □ Difficulty swallowing □ Oral ulcers □ Cold sores □ Teeth grinding □ Other_________________ SKIN □ Hives □ Rashes □ Eczema □ Itching □ Night sweating □ Excess sweating □ Dry skin □ Bruise easily □ Changes in moles/lumps □ Other_________________ RESPIRATORY □ Chronic cough □ Coughing up blood □ Coughing up phlegm □ Difficulty breathing □ Wheezing/Asthma □ Frequent colds □ Pneumonia □ Other _______________

CARDIOVASCULAR □ Palpitations □ Chest pain or tightness □ Rapid heart beat □ Irregular heart beat □ Poor circulation (cold hands/feet) □ Swelling of ankles □ Phlebitis □ Other__________________ GASTROINTESTINAL □ Indigestion □ Bloating □ Gas □ Frequent belching □ Stomach pain □ Diarrhea □ Constipation □ Nausea □ Vomiting □ Vomiting blood □ Low appetite □ Excessive hunger □ Bad breath □ Blood in stools/black stools □ Hemorrhoids □ Gallbladder disorder □ Recent weight change □ Food cravings ________________ □ Other_______________________ NEUROLOGICAL □ Tremors □ Numbness or tingling of limbs □ Paralysis □ Concussion □ Other_______________________ MUSCULOSKELETAL □ Sore or painful muscles □ Weak muscles □ Muscle spasms, twitches □ Back pain □ Tendonitis □ Joint pain □ Other_______________________ UROGENITAL □ Pain/itching of genitalia □ Genital lesions/discharge □ Painful urination □ Frequent urination □ Blood in urine □ Kidney or UB stones □ Diminished bladder control □ Other_______________________

FEMALE □ Frequent urinary tract infections □ Frequent vaginal (yeast) infections □ Pelvic Inflammatory Disease □ Abnormal Pap smear □ Uterine fibroids □ Irregular periods □ Painful menstrual periods □ Premenstrual Syndrome (PMS) □ Abnormal bleeding □ Hot flashes □ Other menopausal symptoms □ Breast pain/tenderness □ Breast lumps □ Nipple discharge □ Other_______________________ Date of last period________________ Date of last Pap smear_____________ Were Pap smear results normal? (circle) Yes No Date of last mammogram__________ Are you pregnant?________________ Are you nursing?_________________ Do you use birth control? (circle) Yes No Type _____________ MALE □ Prostate problem □ Lumps in testicles □ Weak urinary stream □ Impotence □ Other_______________________ GENERAL □ Insomnia □ Frequent dreams/nightmares □ Anxiety □ Irritability □ Forgetfulness □ Depression □ Fatigue □ Feel hot or cold (circle) □ Aversion to heat or cold (circle) □ Fever and/or chills □ Strong thirst □ Psychiatric Treatment □ Other_______________________