T.W.U. Institute for Women's Health Pioneer Project

Year 1 Medical History Questionnaire
Personal Medical History

Section 3: Review of Systems


Please indicate whether you have had a significant problem with any of the symptoms or conditions listed below. If it is a problem that has happened more than once, mark "recurring" as well as all ranges of years in which it happened.

15. GENERAL
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Unexplained weight loss
Chronic fatigue
Change in appetite
Night sweats
Fever or chills
Any type of cancer
Sleep disorder
Eating disorder
 
16. EAR-NOSE-THROAT
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Hearing loss
Prolonged exposure to loud noise
Ringing in ears
Chronic ear infection
Ruptured eardrum
Sinus infection
Vertigo
Vocal cord polyp
Laryngitis
Epiglottitis
Strep throat
 
17. EYES
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Decrease in vision
Double vision
Glaucoma
Color blindness
Cataracts
Serious injury to the eye
Macular degeneration of retina
Wear glasses to see far away
Wear glasses to see close up
Wear glasses to read
Wear contact lenses to see far away
Wear contact lenses to see close up
Wear contact lenses to read
 
18. ENDOCRINE
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Thyroid disease
     Hyperthyroidism (high)
     Hypothyroid (low)
High blood sugar
Diabetes requiring insulin
Diabetes not requiring insulin
Hyperparathyroidism