Trouble swallowing Change in thirst Abdominal pain or cramps Change in appetite Excessive belching or excess gas Nausea/vomiting Burning pain in stomach Jaundice Black Gallbladder disease Blood in stools Liver disease Bowel movement (BM) daily How often are BMs: _____________ Musculoskeletal Joint pain or stiffness Arthritis Broken Weakness Sciatica Muscle spasms or cramps Blood/Peripheral Vascular Easy bleeding/bruising Cold hands Deep leg pain Cold feet Varicose clots Anemia Reproductive Health Genital herpes Gonorrhea Syphilis Condyloma/genital warts HIV Male Reproduction Premature ejaculation Prostate disease Testicular masses or pain Erectile dysfunction Discharge or sores on penis Delayed orgasm Use condoms? Y/N Sexually active Female Reproduction Age at first menses (period)_______ Light flow Last menses __________________ Bleeding/spotting between periods Usual length of cycle (blood flow to next blood flow)_______ Discharge Irregular Painful menses Menopausal symptoms Heavy flow
Trouble swallowing Change in thirst Change in appetite Nausea/vomiting Burning pain in stomach Jaundice Gallbladder disease Liver disease Abdominal pain or cramps Excessive belching or excess gas Black Blood in stools Bowel movement (BM) daily How often are BMs: _____________ Musculoskeletal Joint pain or stiffness Broken Muscle spasms or cramps Arthritis Weakness Sciatica Blood/Peripheral Vascular Easy bleeding/bruising Deep leg pain Varicose Anemia Cold hands Cold feet clots Reproductive Health Gonorrhea Condyloma/genital warts Genital herpes Syphilis HIV Male Reproduction Prostate disease Erectile dysfunction Delayed orgasm Premature ejaculation Testicular masses or pain Discharge or sores on penis Use condoms? Y/N Sexually active Female Reproduction Age at first menses (period)_______ Last menses __________________ Usual length of cycle (blood flow to next blood flow)_______ Irregular Painful menses Heavy flow Light flow Bleeding/spotting between periods Discharge Menopausal symptoms
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