Heart or Do you ever have pain/tightness in your chest when Breathing Yes No ☐ ☐ working or exercising? Do you wake up at night with trouble breathing? Yes No ☐ ☐ Do you have a racing or skipping heartbeat at times? Yes No ☐ ☐ Do you have other heart or breathing problems? Yes No ☐ ☐ Bowel Do you have bowel movements (poop) that are black, like Movements Yes No ☐ ☐ tar, or bloody? Do you have any other problems with your bowel Yes No ☐ ☐ movements (poop)? Peeing and Do you have trouble passing your urine (peeing) Yes No ☐ ☐ Kidney Stones Does it burn when you pass urine (pee)? Yes No ☐ ☐ Do you have to pee more than 2 times a night? Yes No ☐ ☐ Do you leak urine (pee)? Yes No ☐ ☐ Have you ever passed kidney stones? Yes No ☐ ☐ Do you have any other problems with your peeing? Yes No ☐ ☐ Joints Do you have swollen or painful joints? Yes No ☐ ☐ Do you have any other problems with your joints? Yes No ☐ ☐ REVIEW OF SYMPTOMS CONTINUED Head, Do you have frequent or severe headaches? Yes No ☐ ☐ Balance, Fever and Have you ever fainted (passed out)? Yes No ☐ ☐ Weakness Have you lost your balance and fallen recently? Yes No ☐ ☐ Do you have weakness in any part of your body? Yes No ☐ ☐
Heart or Breathing Do you ever have pain/tightness in your chest when working or exercising? ☐ Yes ☐ No Do you wake up at night with trouble breathing? ☐ Yes ☐ No Do you have a racing or skipping heartbeat at times? ☐ Yes ☐ No Do you have other heart or breathing problems? ☐ Yes ☐ No Bowel Movements Do you have bowel movements (poop) that are black, like tar, or bloody? ☐ Yes ☐ No Do you have any other problems with your bowel movements (poop)? ☐ Yes ☐ No Peeing and Kidney Stones Do you have trouble passing your urine (peeing) ☐ Yes ☐ No Does it burn when you pass urine (pee)? ☐ Yes ☐ No Do you have to pee more than 2 times a night? ☐ Yes ☐ No Do you leak urine (pee)? ☐ Yes ☐ No Have you ever passed kidney stones? ☐ Yes ☐ No Do you have any other problems with your peeing? ☐ Yes ☐ No Joints Do you have swollen or painful joints? ☐ Yes ☐ No Do you have any other problems with your joints? ☐ Yes ☐ No REVIEW OF SYMPTOMS CONTINUED Head, Balance, Fever and Weakness Do you have frequent or severe headaches? ☐ Yes ☐ No Have you ever fainted (passed out)? ☐ Yes ☐ No Have you lost your balance and fallen recently? ☐ Yes ☐ No Do you have weakness in any part of your body? ☐ Yes ☐ No
healthlittoolkit2-tool11a.docx