1. Signs and Symptoms

2. Do you have or have you ever had __________? (Related to GI) abdominal distention abdominal pain abdominal rigidity bad breath belching black, tarry stool bloody stools breath with fecal odor clay-colored stools constipation diarrhea difficulty swallowing excessive appetite fecal incontinence gas heartburn hiccups indigestion increased salivation loss of appetite musty sweet breath odor nausea rectal bleeding rectal pain stomach growling

3. Do you have or have you ever had____________? (Related to lung) blue discoloration of skin clubbing of the fingers or toes cough/barking, nonproductive/ productive coughing up blood deep breathing difficulty breathing when lying down fast breathing nasal flaring wheezing

4. Do you have or have you ever had_____________? (Related to the heart) chest pain cramping leg pain fast heart rate heart attack high blood pressure pale skin red lesions on the palms of hands and soles of the feet slow heart rate sudden shortness of breath at night tender, red or purple lesions on the palms, soles, finger pads, and toes

5. Do you have or have you ever had__________? (related to bladder) bladder distention blood in the urine decreased urine increased urination nighttime urination painful urination urinary frequency urinary hesitancy urinary incontinence urinary urgency urine cloudiness

6. Do you have or have you ever had__________? (rashes, itching, irritation) Bleeding under the skin Butterfly rash change in skin color hives increasing hair loss itching papular rash(small, raised bumps) rash with filled bubbles red skin or irritation skin that’s scaly/oily/ dry sores spots on the hands or legs(black, brown, purple, red) thin, purple, red) thin, purple streaks on the skin

7. Do you have or have you ever had__________? (Related to neck and neck up) difficulty speaking decreased salivation drooping mouth facial pain gum swelling or bleeding hoarseness increase salivation jaw clicking jaw locking mouth lesions nasal drainage nosebleeds postnasal drip sinus pain swelling of the face/ the jaw/the mouth/ the nose throat pain or sore throat toothache

8. Do you have or have you ever had__________? (related to eyes) abnormal eye movement area of partial or complete blindness blindness in one eye bulging of the eyes double vision drainage from the ear earache eye drainage eye pain eye watering or redness halo vision hearing loss involuntary eye movement light flashes night blindness ringing or buzzing in the ears sensitivity to light sunken eyes swelling of the eyes tunnel vision vision loss visual blurring

9. Do you have or have you ever had__________? (related arm and legs) arm pain back pain bruises bumps enlarged finger joint leg pain muscle spasm muscle weakness swelling, generalized of the arm/of the fingers/of the leg

10. Do you have or have you ever had__________? (Related to brain) anger agitation anxiety depression amnesia(loss of memory) aura confusion decreased level of consciousness difficulty talking difficulty waking dizziness drooling footdrop seizure taste abnormalities tics(twitching) vertigo(spinning or dizzy feeling) headache insomnia loss of consciousness muscle spasm muscle twitching sleepiness swallowing problems eyelid droop neck pain neck stiffness numbness or tingling paralysis raccoon eyes

11. Do you have or have you ever had__________? (related immune system) breath with ordor cold intolerance heat intolence excessive thirst fatigue fever salt craving sweating cold sweat weight gain weight loss