Have you had a fever within the past month? Yes No ☐ ☐ Do you have any other problems with your head or Yes No ☐ ☐ balance? Emotional Do you get upset easily? Yes No ☐ ☐ Health Do frightening thoughts keep coming into your mind? Yes No ☐ ☐ Have you ever been hospitalized for nerves, thoughts or Yes No ☐ ☐ moods? During the past 2 weeks, have you often been bothered by Yes No ☐ ☐ having little interest or pleasure in doing things? During the past 2 weeks, have you often been bothered by Yes No ☐ ☐ feeling down, depressed, or hopeless? Do you have any other problems with your emotional Yes No ☐ ☐ health? Men Only Have you ever had prostate trouble? Yes No ☐ ☐ Do you have any other male problems? Yes No ☐ ☐ Women Do you have pain or lumps in your breast? Yes No ☐ ☐ Only Do you have unusual vaginal discharge or itching? Yes No ☐ ☐ Do you or have you taken hormones (such as birth control Yes No ☐ ☐ pills)? Do you have any other female problems? Yes No ☐ ☐
Have you had a fever within the past month? ☐ Yes ☐ No Do you have any other problems with your head or balance? ☐ Yes ☐ No Emotional Health Do you get upset easily? ☐ Yes ☐ No Do frightening thoughts keep coming into your mind? ☐ Yes ☐ No Have you ever been hospitalized for nerves, thoughts or moods? ☐ Yes ☐ No During the past 2 weeks, have you often been bothered by having little interest or pleasure in doing things? ☐ Yes ☐ No During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless? ☐ Yes ☐ No Do you have any other problems with your emotional health? ☐ Yes ☐ No Men Only Have you ever had prostate trouble? ☐ Yes ☐ No Do you have any other male problems? ☐ Yes ☐ No Women Only Do you have pain or lumps in your breast? ☐ Yes ☐ No Do you have unusual vaginal discharge or itching? ☐ Yes ☐ No Do you or have you taken hormones (such as birth control pills)? ☐ Yes ☐ No Do you have any other female problems? ☐ Yes ☐ No