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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 12 / 14

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Constitutional

  • Fatigue

  • Weight loss

  • Weight gain

  • Change in bowel habits

Eyes

  • Change in visual acuity

  • Double vision

  • Transient visual loss

ENT

  • Difficulty swallowing

  • Hearing loss

  • Change in smell

Cardiovascular

  • Chest pain

  • Angina

  • Irregular heart rate

  • High blood pressure

  • Leg pan; arm pain

  • Vascular changes in extremity

Respiratory

  • Shortness of breath

  • Chronic cough

  • Cough up blood

  • Wheezing

Gastrointestinal

  • Abdominal pain

  • Diarrhea

  • Constipation

  • GI bleeding

  • Jaundice

Genitourinary

  • Incontinence

  • Blood in urine

  • Cannot urinate

  • Female problems

  • Male problems

REVIEW OF SYSTEMS

Skin

  • Skin Lesions

Neurological

  • Seizures

  • Numbness in extremities

  • Muscle weakness

  • Paralysis

  • Tremor

  • Difficulty with gait

  • Involuntary movements

  • Vertigo

  • Unsteadiness of gait

  • Facial pain

  • Difficulty with speech

Psychiatric

  • Intellectual loss

  • Depression

  • Anxiety

  • Panic spells

Endocrine

  • Hormone problems

  • Diabetes

  • Thyroid disease

  • Other endocrine disease

Musculoskeletal

  • Back pain

  • Neck pain

  • Joint swelling

  • Motor weakness

  • Extremity pain

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 10 of 11

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