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Health Questionnaire
Name
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To select more than one hold the Ctrl Key
Men Only
Burning or Discharge
Swelling on testicles
Painful Testicles
Women Only
painful menstruation
menstrual problems
heavy bleeding
genital irritation
swelling of breasts
endometriosis
missed periods
hot flashes
vaginal discharge
pain on intercourse
uterine fibroids
menopause
Mind
lack of concentration
loss of memory
depression
frequent crying
worrisome
cry easily
shy or sensitive
dislike criticism
angered easily
nervousness
restlessness
anxiety
convulsions
moodiness
excessive fear
irritability
Vertigo
Dizziness
loss of consciousness
dizzy spells
fainting
loss of balance
Eye
headaches
migraines
blurry vision
eye pain or itching
double vision
cataracts
Ear
ear pain
hearing loss
ringing in the ears
Nose
sinus congestion
sneezing
nose bleeds
hay fever
Mouth
sore or bleeding gum
Teeth
Dental problems
Throat
sore throats
difficulty swallowing
vomiting blood
wheezing or gasping
frequent coughs
thyroid problems
Stomach
heartburn
indigestion
frequent belching
nausea
vomiting
Abdomen
pain in abdomen
bloated abdomen
constipation
Stool
loose bowels
black stools
Rectum
pain in rectum
itching of rectum
rectal bleeding
Bladder
frequent urination
involuntary urination
burning on urination
blood in urine
constant urge for urination
Respiratory
cough
asthma
wheezing
gasping
Chest
cough
expectoration
chest pain
colds
shortness of breath
heart palpitations
Back
Spine curvature
back pain
Extremities
broken bones
aching muscles or joints
swollen joints
joint pain
leg cramps
twitching
Sleep
insomnia
difficulty sleeping
Skin
skin problems
eczema
acne
hives
warts
poison Ivy
yellow jaundice
Perspiration
excessive sweating
Chill
cold intolerance
Fever
heat intolerance
unexplained fevers
Generalities
blood pressure
weigh gain
weight loss
anemia
appetite change
fatigue or weariness
change of sexual energy
polyps
cysts
convulsions
allergies
varicose veins
artificial organs
broken bones
poison Ivy
Hemorrhoids
motion sickness
fainting/blackouts
numbness, trembling
slow healing wounds
bruise easily
bleeding easily
prolonged bleeding
twitching
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