Lippincott Williams & Wilkins
( Sores in mouth ( Pus in urine ( No ( Yes If yes, at what age: ____ (Loss of taste ( Discharge from penis/vagina Date of last Pap smear: _____ ( Dryness ( Frequent urination Date of last mammogram: _____ ( Recent increase in tooth cavities ( Getting up at night to pass urine ( Vaginal dryness If you are still having periods: NOSE ( Rash/ulcers ... ................
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