SYSTEMS:
Do you now have or have you ever had:
Yes
Any eye disease, injury, impaired sight...
Any ear disease, injury, impaired hearing. .
Any trouble with nose, sinuses 3 mouth, throat
Fainting spells .....-.
Loss of consciousness ....
Convulsions 2... 1. 2 6 ee
Paralysis . 2. 6 2 + es ee we
Dizziness 2... «6 se ew wae
Frequent or severe headaches
Depression or anxiety... .
Hallucinations .....-e-.
Enlarged thyroid or goiter
Enlarced glands .....4..
Skin disease . + ese eae
Chronic or frequent cough. .
Chest pain or angina pectoris
....
Spitting up of blood
Night sweats
Shartness
at
ww
..... 5.6.
heaath
we ws
a
.
*
e
o
*
Palpitation or fluttering heart
Ls
.
Swelling of hands, feet or ankles rr
Varicose veins
.....ee-s.
Extreme tiredness or weakness
Kidney disease or stones
..
Bladder disease . ... ee
Albumin, sugar, pus, etc.
*
.
*
a
s
s
4
s
*
*
e
*
.
.
.
s
.
e
«
s
s
s
'
°
*
e
°
s
a
in urine
Difficulty in urinating...
*
.....
e
Abnormal thirst ......-.
Stomach trouble or ulcer ...
Indigestion... 2... 2 ee
Appendicitis ....
.
Liver or gal] bladder disease
Colitis or other bowel disease
Hemorrhoids or rectal bleeding.
Constipation or diarrhea
..
Has there been any recent change in:
~
Your appetite or eating habits
Your bowel action or stools .
e
*
e
*
a
No
Unknown