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General
- Have you had any fever?
- Have you had any chills?
- Have you had any (night) sweats?
- Have you had any weight loss or weight gain?
- Have you been tired or fatigued?
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Dermatologic
- Have you noticed a rash or skin lesion?
- Does it itch or burn?
- Have you had any changes in moles (size, color, border irregularity)?
- Have you had any changes in hair texture?
- Have you had any changes in nails?
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Head & Neck
- Have you had any headaches? Where?
- Have you had any neck pain?
- Have you noticed any neck masses or “swollen glands”?
- Have you had any neck stiffness?
- Have you had any dizziness or lightheadedness?
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Ear
- Have you had any hearing loss?
- Do you use hearing aid(s)?
- Have you had any ear pain or earaches?
- Have you had any ringing in the ears (tinnitus)?
- Have you had any discharge/blood/pus from the ears?
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Nose
- Have you had any nasal discharge? What color?
- Have you had any nose bleeds (epistaxis)?
- Have you had any sinus pains or pressure?
- Have you had any post-nasal drip?
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Throat & Oral Cavity
- Have you had any sores in your mouth?
- Have you had any tooth or gum problems?
- Have you had a sore throat?
- Have you noticed any hoarseness?
- Do you wear dentures?
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Eyes
- Have you had a change in vision?
- Do you use glasses or contact lenses?
- Have you had any double vision (diplopia)?
- Have you had blurred vision?
- Any redness of your eyes?
- Any discharge from your eyes?
- Any excessive tearing or dryness in your eyes?
- Have you had any trauma to your eyes?
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Breast
- Have you noticed any lumps/masses?
- Have you had any breast pain or tenderness?
- Have you had any discharge from the nipple?
- Do you have any “swollen glands” under your arms?
- Do you perform monthly self-exams on your breasts?
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Pulmonary
- Have you had a (new/different) cough?
- Have you brought up any phlegm? What color?
- Have you coughed up blood (hemoptysis)?
- Have you had pain with breathing (pleuritic pain)?
- Have you had shortness of breath?
- Have you had any wheezing?
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Cardiovascular
- Have you had any chest pain?
- Have you been short of breath?
- *with exertion (dyspnea on exertion)
- *while lying flat (orthopnea)
- *suddenly while sleeping (paroxysmal nocturnal dyspnea)
- Have you had any palpitations?
- Have you had any swelling in legs or feet (edema)?
- Have you had any pain in the calves while walking (claudication)?
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Abdominal
- Have you had any difficulty swallowing (dysphagia)?
- Have you had pain on swallowing (odynophagia)?
- Have you had any heartburn? (Characterize it further)
- Are you having any abdominal pain?
- Have you had a loss of appetite (anorexia)?
- Have you had any nausea?
- Have you had any vomiting?
- Have you had any diarrhea?
- Have you had any constipation?
- Have you noticed a change in bowel habits?
- Have you had any black, tarry stools (melena)?
- Have you had any bloody stools (hematochezia) or bright red blood per rectum (BRBPR)?
- Have you noticed a change in the caliber of stool size?
- Have you noticed your skin or eyes turning yellow (jaundice)?
- Have you had hemorrhoids?
- Have you noticed any easy bleeding or bruising?
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Genito-Urinary
- Have you had to urinate more frequently?
- Do you feel the urge to urinate more often (urgency)?
- Have you had any pain or burning on urination (dysuria)?
- Have you noticed any blood in urine (hematuria)?
- Have you had any problem with loss of urine or bladder control (urinary incontinence)?
- Do you wake up at night to urinate (nocturia)? How often?
- Have you had a change in urine color or odor?
- Males:
- *Do you have difficulty starting your stream?
- *Have you noticed any lesions on your penis?
- *Have you had any penile discharge?
- *Have you had any problems achieving or maintaining an erection?
- *Have you noticed any scrotal or testicular masses?
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Gynecological
- Describe the frequency, regularity, discomfort and heaviness of menses.
- Have you any change in the discomfort/pain with menses?
- Have you had spotting between menses, or any post-menopausal bleeding?
- Have you had any “hot flashes”?
- Have you noticed vaginal dryness?
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Sexual History
- Are you sexually active? Have you noticed a change in your libido?
- Have you noticed any changes or problems in your sexual functioning?
- Has illness (if applicable) affected your sexual functioning?
- Are you using condoms to prevent disease?
- Are you using birth control - what type?
- Are you in a monogamous relationship?
- For men:
- *Have you had any problems developing or maintaining an erection?
- *Have you had any trouble having an orgasm?
- For women:
- *Have you had pain during intercourse?
- *Have you had difficulty having an orgasm?
- *Have you had problems with lubrication?
- Have you had any concerns about getting a sexual disease or AIDS?
- Have you had any other questions or concerns about this subject?
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Musculoskeletal
- Have you had any pain in your joints? Which ones?
- Have you noticed any joint or muscle stiffness?
- Have you had any joint swelling? (Which joint?)
- Have you noticed any muscle weakness?
- Have you had any muscle tenderness?
- Have you had any back pains? (Upper back?Lower back?)
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Neurological
- Have you had any numbness (paresthesias)? Where?
- Have you had any tingling (dysesthesias)? Where?
- Have you had any problems with your memory?
- Have you had any headaches? Where?
- Have you noticed any dizziness (Vertigo)?
- Have you had any problems with tremors (shaking)?
- Have you had any episodes of blacking out (syncope) or loss of consciousness?
- Have you had any problems with unsteadiness or balance?
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Psychiatric
- Have you had any problems with anxiety?
- Have you had any problems with depression?
- Ask about symptoms of depression (SIGECAPS).
- Do you have any:
- *difficulty getting to Sleep or waking up early (insomnia)?
- *loss of Interest in doing things (anhedonia)?
- *feelings of Guilt?
- *lack of Energy, fatigue?
- *problems with Concentration?
- *loss of Appetite (anorexia) or increase in appetite?
- *problems with slow thinking or moving (Psychomotorslowing)?
- *thoughts of Suicide?
- Have you seen people or things that others did not see? (Hallucinations)
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