REASOS FOR VISITIG THE DOCTOR

Please answer the questions and indicate the symptoms which most closely describe
your current problem. Please tick each of the relevant circles.

1-How long have you been ill?

...........hours ...........days ..........weeks ..........months ............years

Why do you need to see the doctor now? (you may indicate more than one reason)

2- O I have fever.........................................How many degrees?.......................

Since (date)......................................
3- O I have a headache.............................Since (date)......................................
4- O I'm aching all over...........................Since (date).....................................
5- O I'm exhausted..............................Since (date).....................................
6- O I've lost my appetite.......................................Since (date)......................................
7- O I've lost weight.....................Since (date).................how much?................(in kg)
8- O I've put on weight................Since (date).................how much?................(in kg)
9- O I'm sweating heavily.................................Since (date).....................................
10-O I feel sick...........................................Since (date)......................................
11-O I keep falling asleep...................................Since (date).....................................
12-O I'm not sleeping well.......................................Since (date).....................................
13-O Loss of consciousness.......Date....................Duration.................................
14-O Convulsions............................................Date.................................................
15- O I have a cold.........................................Since (date).....................................
16-O I have a sore throat................................Since (date).....................................
17-O I have a nosebleed....................................Since (date).....................................
18-O I have earache.......................................Since (date)....................................
19-O I have a hearing problem...........................................Since
(date).....................................
20-O I have toothache.............................Since (date).....................................
21-O I have a cough................................................ .Since (date)....................................
22-O I make noises when I breathe.......................... .Since (date)
23-O I have difficulty breathing....................................Since
(date).....................................
24-O I'm bringing up saliva.................................................With blood O, Without
blood O.
Since (date).....................................
25-O I have chest pains............................Since (date).....................................
26-O My heart is beating........................................faster O, slower O, irregularly O
Since (date).....................................
27-O I have acid in the stomach.........................Since (date).....................................
28-O I have stomach pains...........................Since (date).....................................
29-O I have abdominal pains..............................Since (date).....................................
30-O I'm constipated..................................Since (date).....................................
31-O I have diarrhoea.............................................Since (date).....................................
32-O I have blood in my stools..........................Since (date)....................................
33-O I have nausea/vomiting.........Since (date)..............With blood O, Without blood
O
34-O I have a body itch ......................................Since (date)....................................
35-O I have skin trouble.........................Since (date)....................................
36-O I have a genital irritation................Since (date)....................................
37-O I have sexual problems........................ .Since (date)....................................
38-O I have erection problems.......................................Since
(date)....................................
39-O I have a pain in my testicles.................................Since
(date)....................................
40-O I have a burning sensation when I urinate....................................Since
(date)....................................
41-O I've seen blood in my urine..................Since (date)....................................
42-O My urine is leaking...................................Since (date)...................................
43-O I have difficulty urinating...........................................Since
(date)...................................
44-O I haven't had my period................Date of last menstruation............................
45-O I'm pregnant........................................Date of last menstruation............................
46-O I have vaginal bleeding ......................Date of last menstruation............................
47-O My periods are painful............................Since (date)...................................
48-O I have a heavy vaginal discharge...........................Since (date).
49-O I'm feeling very unhappy............................................Since
(date)...............................
50-O I'm feeling very nervous.....................................Since (date)..............................
51-O I've taken: Drugs O, Alcohol O
52-O The following has happened to me: I've fallen O, Someone has attacked me O,
I've had a road accident O, I've been raped O
53-O I can't see properly .....................................................Since
(date)............................
I can't see close up O, I can't see at a distance O
My vision is blurred O, I'm seeing double O, I only see partially O
54-O I have a pain (indicate where in the picture) Since (date)...............

If your problem is not covered by any of the above, use the picture to indicate where it
is.