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Check age at death of any relatives if you know it.
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PRESENT COMPLAINTS
1.
Please mark below the chief health problems which you may have now.
Try to mark only most important 2or 3.
the rest of this questionnaire.
Eyes
Fars
Nose
Throat or mouth
Heart
Circulation
Others will be covered in
Kidneys, urine, bladder
Glands (thyroid or other)
Sex organs
Overweight or underweight
Fever
Headaches
Blood pressure or stroke
Lungs and breathing
Allergy (hay fever, hives, asthma)
Stomach and swallowing
Gall bladder, liver, jaundice
Sex problems
Cancer
Disease of the blood
Intestines and bowels
Muscle or joints
Back (spine and neck)
Skin trouble
Brain or head
Nerves or nervousness
Swollen glands
Hernia (rupture)
Neuritises (sciatic or other)
Tiredness-- Loss of pep or energy
Pain
Other medical problems not listed: