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Cardiovascular. Heart trouble, high blood pressure, rheumatic fever, eart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past electrocardiographic or other heart test results.

Gastrointestinal. Trouble swallowing, heartburn, appetite, nausea, bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis.

Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.

Genital. Male: Hernias, discharge from or sores on the penis, testicu-lar pain or masses, history of sexually transmitted diseases and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Exposure to HIV infection. Female: Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding between periods or after intercourse, last menstrual period; dysmenorrhea, premenstrual tension; age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy. Vaginal discharge, itching, sores, lumps, sexually transmitted diseases and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced); complications of pregnancy; birth control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Exposure to HIV infection.

Peripheral Vascular. Intermittent claudication, leg cramps, varicose veins, past clots in the veins.

Musculoskeletal. Muscle or joint pains, stiffness, arthritis, gout, and backache. If present, describe location of affected joints or muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (for example, morning or evening), duration, and any history of trauma.

^^ Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or "pins and needles," tremors or other involuntary movements.

^ Hematologic. Anemia, easy bruising or bleeding, past transfusions and/or transfusion reactions.

Endocrine. Thyroid trouble, heat or cold intolerance, excessive sweat-g, excessive thirst or hunger, polyuria, change in glove or shoe size.

^ Psychiatric. Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant.

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