PATIENT HISTORY FORM - Hopkins Medicine
( Recent weight gain; how much____ ( Headaches ( Depression ( Recent weight loss: how much____ ( Dizziness ( Excessive worries ( Fatigue ( Fainting or loss of consciousness ( Difficulty falling asleep ( Weakness ( Numbness or tingling ( Difficulty staying asleep ( Fever ( Memory loss ( Difficulties with sexual arousal ( Night sweats ................
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