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Have you had trouble with the following?

Allergic/Immunologic   No   Neurological   No
  Present Past No     Present Past No
Hives   Stroke
Immune Disorder   Seizures
HIV/AIDS   Head Injury
Allergy Shots   Brain Aneurysm
Cortisone Use   Numbness
    Severe Headaches
Gastrointestinal   No   Pinched Nerves
  Present Past No   Parkinson's Disease
Gal bladder problems   Carpal Tunnel
Bowel Problems   Spinning/balance
Constipation          
Liver Problems   Endocrine   No
Ulcers     Present Past No
Diarrhea   Thyroid Disease
Nausea/Vomiting   Diabetes
Bloody Stools   Hair Loss
Poor Appetite   Menopausal
          Menstrual Problems
Musculoskeletal   No    
  Present Past No   Psychiatric   No
Gout     Present Past No
Arthritis   Depression
Joint Stiffness   Anxiety Disorder
Muscle Weakness   Unusual Stress
Osteoporosis          
Broken Bones   Constitutional   No
Joints Replaced     Present Past No
    Weight Loss/Gain
    Energy Level problem
    Difficulty Sleeping

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