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