Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 2 Name Cardiovascular Urinary Name *FirstLastHeadHair LossEyesDifficulty focusing visionDouble VisionDrynessIncrease or decrease in tearingItching, burning or dischargeVision changesEarsEar PainHearing changesRinging in earsNoseCold or flu like symptomsCongestionNosebleedsSinus pain or pressureMouth & ThroatDifficulty swallowingDrynessMouth painSore throatVocal changesCardiovascularChest pain or tightnessEdemaHeart poundingMurmurPalpitationsRespiratoryCoughPain with breathingPhlegmShortness of breathWheezeGastrointestinalAbdominal pain/bloatingBlack or tarry stoolsConstipationDiarrheaFood intoleranceHeartburnHemorrhoidsNausea/VomitingRectal bleedingUrinaryBlood in urineDifficulty urinatingFrequent urinationPainful urinationNextGeneral *AgitatedChillsConstant worryDecrease in sex driveDizzy or light headedEasy bruisingExcessive feelings of guiltFainting or feeling faintFatigue or lack of energyFear of doing something uncontrollableFear of dyingFear of going crazyFear of losing controlFearful feelingsFeeling in a dream-like stateFeeling life is not worth livingFeverFrequent crying or weepingFrequent negative thinkingFrequent thoughts of death or suicideHeadacheHelpless feelingsHopeless feelingsIncrease or decrease in appetiteIncrease or decrease in weightInsomnia or trouble sleepingIrritabilityJumpinessKeyed up or on edgeLack or loss of interest in thingsMemory problemsNervousnessRepetitive, senseless behaviorRepetitive, senseless thoughtsRestlessnessSad, depressed or down in the dumpsSeeing or hearing things that are not realSeizuresSkin rashSleeping too muchSweatingTensionTremors, trembling or shakinessTrouble making decisionsViolent behaviorWeaknessWorthless feelingsNO SYMPTOMS TO REPORTSubmit
