586 ●^ APPENDIX H
Do you have (or have you ever had) any of the following? If yes, provide explanation on the back of this sheet. Ye s No Ye s NoYe s No
Blood clots/pain in legs 1. Diffi (^) culty swallowing 14. Fainting spells 2. Delayed wound healing^ 15. Swollen ankles/legs/hands 3. Constipation problems 16. Asthma 4. Urination problems^ 17. Varicose veins^ 5. Recent change in elimination18. Numbness/tingling patterns (location?) (^) 6. Weakness or tremors^ 7. Seizures^ 19. Ulcers (^) 8. Headaches^ 20. Nausea/vomiting 21. Problems with diarrhea (^) 9. Dizziness^ 10. High blood pressure 22. Shortness of breath^ 11. Palpitations^ 23. Sexual dysfunction^ 12. Chest pain
Lumps in your breasts^ 25. Blurred or double vision^ 26. Ringing in the ears^ 27. Insomnia^ 28. Skin rashes^ 29. Diabetes^ 30. Hepatitis (or other liver disease)^ 31. Kidney disease^ 32. Glaucoma^
2 2506_Appendix_H_583-587.indd 586 506 _AppendixH 583 - 587 .indd 586 10/1/10 9:31:02 AM 10 / 1 / 10 9 : 31 : 02 AM