REVIEW OF SYMPTOMS Sleeping Do you feel tired a lot? Yes No ☐ ☐ Do you have trouble falling or staying asleep? Yes No ☐ ☐ Do you have other problems with sleep? Yes No ☐ ☐ Eating Have you recently? Yes No lost your appetite ☐ ☐ Have you lost weight in the last year without trying? Yes No ☐ ☐ Do you eat too much or have you gained weight recently? Yes No ☐ ☐ Do you have Yes No other problems with eating? ☐ ☐ Do you have sore throats a lot? Yes No ☐ ☐ Do you have other problems with your throat? Yes No ☐ ☐ Throat Ears Do you have trouble hearing? Yes No ☐ ☐ Do you wear a hearing aid? Yes No ☐ ☐ Do you have constant in your ears? Yes No ringing or noises ☐ ☐ Do you have other problems with your ears? Yes No ☐ ☐ Back Do you have back pain? Yes No ☐ ☐ Do you have any other problems with your back? Yes No ☐ ☐ Eyes Do you have trouble with your vision or seeing? Yes No ☐ ☐ Do you wear glasses or contacts? Yes No ☐ ☐ Do you have other problems with your eyes? Yes No ☐ ☐ Nose and Do you have a runny or stopped up nose a lot? Yes No ☐ ☐ Sinuses Do you have other problems with your nose or sinuses? Yes No ☐ ☐ Teeth and Do you have sore or bleeding gums? Yes No ☐ ☐ Mouth Do you wear plates or false teeth? Yes No ☐ ☐ Do you have other problems with your teeth and mouth? Yes No ☐ ☐ REVIEW OF SYMPTOMS CONTINUED
REVIEW OF SYMPTOMS Sleeping Do you feel tired a lot? ☐ Yes ☐ No Do you have trouble falling or staying asleep? ☐ Yes ☐ No Do you have other problems with sleep? ☐ Yes ☐ No Eating Have you lost your appetite recently? ☐ Yes ☐ No Have you lost weight in the last year without trying? ☐ Yes ☐ No Do you eat too much or have you gained weight recently? ☐ Yes ☐ No Do you have other problems with eating? ☐ Yes ☐ No Throat Do you have sore throats a lot? ☐ Yes ☐ No Do you have other problems with your throat? ☐ Yes ☐ No Ears Do you have trouble hearing? ☐ Yes ☐ No Do you wear a hearing aid? ☐ Yes ☐ No Do you have constant ringing or noises in your ears? ☐ Yes ☐ No Do you have other problems with your ears? ☐ Yes ☐ No Back Do you have back pain? ☐ Yes ☐ No Do you have any other problems with your back? ☐ Yes ☐ No Eyes Do you have trouble with your vision or seeing? ☐ Yes ☐ No Do you wear glasses or contacts? ☐ Yes ☐ No Do you have other problems with your eyes? ☐ Yes ☐ No Nose and Sinuses Do you have a runny or stopped up nose a lot? ☐ Yes ☐ No Do you have other problems with your nose or sinuses? ☐ Yes ☐ No Teeth and Mouth Do you have sore or bleeding gums? ☐ Yes ☐ No Do you wear plates or false teeth? ☐ Yes ☐ No Do you have other problems with your teeth and mouth? ☐ Yes ☐ No REVIEW OF SYMPTOMS CONTINUED
healthlittoolkit2-tool11a.docx