Dry Eye Yes No □ □ Eye Pain Yes No □ □ Eye Problems Yes No □ □ Itching Yes No □ □ Red Eye Yes No □ □ ENT: Hoarseness Yes No □ □ Nasal Discharge Yes No □ □ Loss of Hearing Yes No □ □ Ear Pain Yes No □ □ Nosebleed Yes No □ □ Endocrinology: Acne Yes No □ □ Diabetes Yes No □ □ Excessive Thirst Yes No □ □ Hair Loss Yes No □ □ Hot Flashes Yes No □ □ Weakness Yes No □ □ Respiratory: Asthma Yes No □ □ Cough Yes No □ □ Shortness of Breath Yes No □ □ Lung Disease Yes No □ □ Wheezing Yes No □ □ Cardiovascular: Heart Attack Yes No □ □ Chest Pain Yes No □ □ Pacemaker Yes No □ □ CHF Yes No □ □ Angioplasty (Stent) Yes No □ □ Irregular Heartbeat Yes No □ □ Angina Yes No □ □ Gastrointestinal: Ulcer Yes No □ □ Abdominal Pain Yes No □ □ Blood in stool Yes No □ □ Constipation Yes No □ □ Diarrhea Yes No □ □ Heartburn Yes No □ □ Vomiting Yes No □ □ Hematology: Anemia Yes No □ □ Bleeding Problems Yes No □ □ Easy Bruising Yes No □ □ Prolonged Bleeding Yes No □ □ Genitourinary: Pain while Urinating Yes No □ □ Urethral Discharge Yes No □ □ Pain in Pelvis Yes No □ □
Dry Eye □ Yes □ No Eye Pain □ Yes □ No Eye Problems □ Yes □ No Itching □ Yes □ No Red Eye □ Yes □ No ENT: Hoarseness □ Yes □ No Nasal Discharge □ Yes □ No Loss of Hearing □ Yes □ No Ear Pain □ Yes □ No Nosebleed □ Yes □ No Endocrinology: Acne □ Yes □ No Diabetes □ Yes □ No Excessive Thirst □ Yes □ No Hair Loss □ Yes □ No Hot Flashes □ Yes □ No Weakness □ Yes □ No Respiratory: Asthma □ Yes □ No Cough □ Yes □ No Shortness of Breath □ Yes □ No Lung Disease □ Yes □ No Wheezing □ Yes □ No Cardiovascular: Heart Attack □ Yes □ No Chest Pain □ Yes □ No Pacemaker □ Yes □ No CHF □ Yes □ No Angioplasty (Stent) □ Yes □ No Irregular Heartbeat □ Yes □ No Angina □ Yes □ No Gastrointestinal: Ulcer □ Yes □ No Abdominal Pain □ Yes □ No Blood in stool □ Yes □ No Constipation □ Yes □ No Diarrhea □ Yes □ No Heartburn □ Yes □ No Vomiting □ Yes □ No Hematology: Anemia □ Yes □ No Bleeding Problems □ Yes □ No Easy Bruising □ Yes □ No Prolonged Bleeding □ Yes □ No Genitourinary: Pain while Urinating □ Yes □ No Urethral Discharge □ Yes □ No Pain in Pelvis □ Yes □ No