First & Last Name
EmphysemaAsthmaPneumoniaUpper RespiratoryInfection BronchitisPulmonary Embolus
Heart AttackChest PainLipids.Heart FailureHigh Blood Pressure TriglyceridesHeart MurmurIrregular Heart Beat Coronary Artery Disease
HepatitisHepatitis AGallstonesCirrhosisHepatitis BUlcersLiver FailureHepatitis CReflux
DiabetesHypothyroidismHashimotoPituitaryParathyroid Hyperthyroidism
HeadacheSeizuresMigrainesStrokeSpeech ProblemBell ’s palsyTremorMyasthenia GravisMultiple Sclerosis
Kidney StonesRenal FailureNephritisBPH
CataractsBlindnessGlaucoma
ArthritisTMJDegenerative Disc DiseaseGOUT Spinal StenosisFibromyalgia
AnemiaLymphoma Bleeding DisordersLeukemia (CLL)Deep Venous Thrombosis
DepressionAnxietyBi-Polar Disorder
Hearing Loss Tinnitus/Ringing in earsVertigo/DizzinessImpacted CerumenExternal Ear InfectionPerforation of Eardrum
NoneMinimalModerateHeavy
YesNo
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