Have you had any significant infections or diseases of the skin?
If yes, please elaborate.
Has your skin changed in character or texture recently?
Are you bothered by severe itching?
Do you bruise easily?
Has your hair changed in amount or texture?
Does your hair fall out easily?
Do you perspire excessively?
Do you suffer frequent headaches?
Do you have sick headaches (migraine)?
Do you faint easily?
Have you ever been knocked unconscious?
Do you have lightheadedness or giddiness?
Do you ever have severe dizziness?
Do you wear glasses?
Do you ever see double?
Have you had any loss of vision?
Have you had inflammation of the eyes?
Do you have difficulty distinguishing colors?
Do you have spots before your eyes?
Date of your last eye exam?
Have you had any loss of hearing?
Have you ever had earaches or discharge?
Do you have buzzing or ringing in your ears?
Have you ever had your ears punctured?
Do you have frequent colds?
Do you have excessive nasal discharge?
Do you ever have frequent or severe nosebleeds?
Have you had sinus trouble?
Have you had excessive trouble with your teeth?
Do your gums bleed frequently?
Do you wear dentures?
Is your tongue frequently sore or sensitive?
Date of your last dental exam?
Have you had frequent or severe sore throats?
Have you had tonsillitis?
Do you have difficulty swallowing?
Are you subject to hoarseness?
Have you had discharging or swollen glands in your neck?
Have you had a goiter?
Have you had a metabolism test or other thyroid tests done?
Does cold or hot weather bother you excessively?
Have you ever been treated for thyroid trouble?
Have you noticed lumps or nodules in your breasts?
Have you had a bloody discharge from your breasts?
Have you had an operation on your breasts?
Date of your last mammogram? (women)
Do you have a chronic cough?
Do you raise more than one tablespoon of sputum daily?
Have you ever coughed up blood?
Do you have night sweats?
Have you been told that you had any lung or bronchial trouble?
Have you had pleurisy?
Have you noticed a wheeze or whistle in your chest or breathing?
Have you ever had close contact with a person who had tuberculosis?
Have you had a skin test for TB?
If yes, when was the test?
Was the test Positive or Negative?
Have you ever been told you have heart disease or murmur?
Have you been told you had high blood pressure?
Do you become winded on climbing two flights of stairs?
Do you have pain or a tight feeling in your chest on exertion?
Do you have to sleep propped up in a bed?
Do your ankles swell?
Do you have palpitations (heart beating rapidly)?
Have you been refused life insurance at normal rates?
Have you noticed any loss of appetite?
Do any foods cause indigestion or diarrhea?
Do you have indigestion or excessive gas?
Do you have pain to your stomach?
Have you vomited blood?
Are you constipated?
Have your bowel habits changed in the past six months?
Do you pass mucous in your stool?
Do you have hemorrhoids (piles)?
Have you been jaundiced (yellow eyes and skin)?
Have you had intestinal worms or parasites?
Have you lost weight in the past year?
If yes, how much?
Date of your last colonoscopy or sigmoidoscopy?
Do you get up every night to urinate?
Do you have burning pain when you urinate?
Have you had pus in the kidneys or urine?
Do you have trouble starting your stream when you urinate?
Have you passed stones or gravel in the urine?
Have you passed blood in the urine?
Have you had albumin in the urine?
Do you ever lose control of your bladder?
Has a doctor ever said you have a kidney or bladder disease?
Have you had sugar in the urine?
Have you had or suspected you had a venereal disease?
Did you ever have painful or swollen joints?
Are you subject to rheumatism?
Have you ever had trouble with your back?
Do you have varicose veins?
Have you ever had phlebitis?
Do you have pain in your legs when walking?
Are you subject to dizziness, fainting, twitching, spells, or fits?
Was any part of your body ever paralyzed?
Do you have shooting pains in your arms or legs?
Do you have numbness or tingling in your fingers or toes?
Have you ever consulted a psychiatrist?
Do you cry easily?
Do you worry very much?
Do you regard yourself as being nervous?
Do you tire very easily?
Are you depressed and blue much of the time?
Is it difficult for you to make up your mind?
Are your feelings easily hurt?
Are you easily irritated and upset?
Does every little thing get on your nerves?
Are you extremely shy or sensitive?
Do people often annoy or irritate you?
Are you constantly keyed up and jittery?
Is your home life unpleasant?
Is your work unpleasant?
Do you bite your fingernails?
Have you ever been hospitalized for psychiatric issues?
For Men
Date of last blood PSA test:
PSA Value:
For Women
Were you older than 15 when your periods began?
Do your periods last more than five days?
Does pain with your periods frequently make you lie down?
Are you usually tense and jumpy with your periods?
Do you have bleeding or discharge between your periods?
Do you have hot flashes?
What was the first day of your last period?
I would like to request an AIDS test (HIV antibody test).