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-General Usual weight, recent weight change, weakness, fatigue, or fever -Skin Rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in size or color moles -Head, Eyes, Ears, Nose, Throat (HEENT): - Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, Tinnitus, Vertigo, earaches, infection, discharge, If hearing is decreased, use or nonuse of hearing aids, Nose and Sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nose- bleeds, sinus trouble. Throat ( or mouth and Pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, sore tongue, dry mouth, frequent sore throats, hoarseness. -Neck “Swollen Glands,” goiter, lumps, pain, or stiffness in the neck. -Breast Lumps, pain, or discomfort, nipple discharge -Respiratory Cough, sputum (color quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (Pleuritic pain). -Cardiovascular “Heart trouble”; high blood pressure; rheumatic fever; heath murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema). -Gastrointestinal Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change bowel habits, pain constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble. -Peripheral Vascular Intermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; past clots in the veins; selling in claves, legs, or feet; color change in fingertips or toes during cold weather; selling with redness or tenderness. -Urinary Frequency or urination, polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. -Genital Male: Hernia, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infection and their treatments. Sexual interest (Libido), function, satisfaction Female: Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal .
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