Circle any of the following symptoms that have recently occurred.

Fever               shaking chills                             excessive sweats                                  fatigue

Significant loss of appetite

Unintentional weight loss of more than five pounds in one month

Weight gain more than five pounds.

Unusual chest pain                    at rest               with mild exertion          with heavy exertion

Palpitations (skipped or irregular heartbeats)

Passing out                   lightheadedness             dizzy spells

Ankle swelling (bilateral /         right      left )

Cough             

Wheezing

Shortness of breath:      with mild exertion                      with heavy exertion

Unusual intolerance to hot or cold temperature

Excessive drinking of fluids. Excessive eating.   Excessive  urinating

Abnormal bruising or bleeding.

Enlarged lymph glands.

Have you ever received a blood transfusion                   yes/ no             how many times? __    

Have you ever donated blood                                       yes / no            how many times ___

Weakness, numbness or tingling.

Urinary frequency, burning or discomfort

Get up to urinate at night more than once?    If yes, how many times  ___

Rash   or hives?

Jaundice: yellowish appearance of your eyes

Significant   weakness, pain or tenderness: 

            If yes: then  in which muscle? joint? or portion of the back?

Any serious problem with sleep?     Difficulty falling asleep              Difficulty staying asleep

Any history of depression?

Any history of a chronic anxiety disorder?

Any history of bipolar disorder?

If the answer to all of the above is No , then place your  initials in this space: _____      

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