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History
How0can0I0help0you0today?
Do0you0have0any0other0symptoms0or0concerns0we0should0discuss?
Do0you0have0any0allergies,0such0as0medications,0food0and/or0latex,0for0example?0Ar
e0you0taking0any0prescripon0medications?
Are0you0taking0any0over-the-counter0or0herbal0medications?
Can0you0tell0me0about0any0current0or0past0medical0problems0you0have0had
?0Any0previous0medical,0surgical,0or0dental0procedures?
Do0you0now0or0have0you0ever0smoked0or0chewed0tobacco?0Hav
e0you0had0any0contact0with0other0sick0people?
Are0you0sexually0active?
Do0you0experience:0chest0pain0discomfort0or0pressure;0pain/pressure/dizziness0with0exert0on0or0
geng0angry;0palpitaon;0decreased0exercise0tolerance;0blue/cold0ngers0or0toes?
Do0you0have0any0of0the0following:0dizziness,0fainng,0spinning0room,0seizures,0weakness,0numbne
ss,0ngling,0tremor?
Do0you0have0any0of0the0following0problems:0fague,0diculty0sleeping,0unintenonal0weight0loss0or0g
ain,0fevers,0night0sweats?
How0high0was0your0fever?
When0you0urinate,0have0you0noced:0pain,0burning,0blood,0dificulty0staring0or0stopping,0dribbling,0inc
onence,0urgency0during0day0or0night0or0any0changes0in0frequency?
How0severe0(1-
10)0is0the0pain0in0your0chest?0Do0you0have0a
ny0pain0in0your0chest?
, R cP S D| 0
2 444 85 87
Have0you0noced:0any0bruising,0bleeding0gums,0nose0bleeds0or0other0sites0of0increased0bleeding?0
Do0you0have0any0of0the0following:0heat0or0cold0intolerance,0increased0thirst,0increased0sweaing,
frequent0urinaon,0change0in0appete?
Do0you0have0any0problems0with:0nervousness,0depression,0lack0of0interest,0sadness,0memory0lo
ss,0or0mood0changes,0or0ever0hear0voices0or0see0things0that0you0know0are0not0there?
Do0you0have0problems0with:0muscle0or0joint0pain,0redness,0swelling,0muscle0cramps,0join
t0sickness,0joint0swelling0or0redness,0back0pain,0neck0or0shoulder0pain,0hip0pain?
Are0you0coughing0up0any0sputum?
When0did0your0cough0start?
Do0you0have0any0problems0with:0headaches0that0don’t0go0away0with0aspirin0or0Tylenol0(acetam
inophen),0double0or0blurred0vision,0dificulty0with0night0vision,0problems0hearing,0ear0pain,0sinus0
problems,0chronic0sore0throats,0dificulty0swallowing?
Have0you0ever0been0hospitalized?0What0is0your0name?
Do0you0have0pain0anywhere?0If0so,0where
?0Physical0Exams
Temperature