CHILLS

FEVER

NIGHT SWEATS

LOSS OF APPETITE

FEELING TIRED OR POORLY

WEIGHT GAIN AMOUNT?

WEIGHT LOSS AMOUNT?

CHRONIC COUGH

WHEEZING

SHORTNESS OF BREATH

JOINT PAIN

JOINT STIFFNESS

SWOLLEN JOINTS

LOW BACK PAIN

MUSCLE PAIN

HEAT OR COLD INTOLERANCE

EXCESSIVE THIRST

EXCESSIVE URINATION

HOT FLASHES

PRURITIS (ITCHING)

SKIN LESIONS

RASHES

EASY BRUISING TENDENCY

SWOLLEN GLANDS

NOSEBLEEDS

WORSENING VISION

BLURRED VISION

VISION DISTORTION

EYE PAIN

NUMBNESS OR TINGLING

DIZZINESS/LIGHTHEADEDNESS

VERTIGO

HEADACHES

WEAKNESS IN ARMS OR LEGS

MEMORY LAPSES OR LOSS

PAIN OF DIFFICULTY WITH URINATION

FREQUENT URINATION

BLOOD IN URINE

INCONTINENCE OF URINE

ANXIETY

DEPRESSION

PANIC ATTACKS

LOSS OF SLEEP

VAGINAL DISCHARGE

HEAVY PERIODS

DISCHARGE FROM PENIS

TESTICULAR PAIN

TESTICULAR LUMP

EARACHE

NASAL DISCHARGE

MOUTH SORES

BLEEDING GUMS

HOARSENESS

THROAT PAIN

FACIAL PAIN

SINUS PAIN

CHEST PAIN/DISCOMFORT

FAST HEART RATE

SWELLING OF LEGS

VARICOSE VEINS

ABDOMINAL SWELLING

ABDOMINAL PAIN

BELCHING

BLACK STOOLS

RED BLOOD IN BOWEL MOVEMENT

CHANGE IN BOWEL MOVEMENT FREQUENCY

CONSTIPATION

DIARRHEA

DIFFICULTY SWALLOWING

FATTY FOOD INTOLERANCE

FULL AFTER EATING SMALL MEAL

BLOATING/GAS

HEARTBURN

HEMORRHOIDS

YELLOW SKIN OR EYES

GALLBLADDER DISEASE

NAUSEA

PAIN WITH SWALLOWING

DECREASE IN APPETITE

RECTAL BLEEDING

RECTAL PAIN

REGURGITATION OF FOOD

INCONTINENCE OF STOOL

VOMITING

VOMITING BLOOD

OTHER – PLEASE LIST

OTHER – PLEASE LIST

OTHER – PLEASE LIST