Type 1 Diabetes Hyperthyroidism (overactive) Type 2 Diabetes Hypothyroidism (underactive) Other form of Diabetes Thyroid nodule(s) Pituitary dysfunction Thyroid cancer Pituitary tumor/adenoma Adrenal dysfunction Growth problem Adrenal tumor/adenoma Male Hypogonadism (low testosterone) Hyperparathyroidism (overactive) Erectile dysfunction Hypoparathyroidism (underactive) Female Hormone dysfunction Kidney stones Cholesterol problem Osteoporosis/Osteopenia Abnormal lab results Other Bone problem Unexplained symptoms

Single Married Widowed Partnered Divorced

Fever/Chills Heat intolerance Inappropriate Weight Gain Cold intolerance Inappropriate Weight Loss Abnormal thirst Fatigue/Malaise Excessive Urination Generalized weakness Insomnia (trouble sleeping) Dizziness Snoring NONE OF THE ABOVE

Visual difficulties Double vision Blurred vision Voice changes Painful swallowing Difficulty swallowing NONE OF THE ABOVE

Neck pain Neck swelling Neck mass NONE OF THE ABOVE

Chest pain Heart racing NONE OF THE ABOVE

Cough Shortness of breath (at rest) Wheezing Shortness of breath (with exertion) NONE OF THE ABOVE

Nausea Vomiting Diarrhea Constipation Abdominal bloating Abdominal pain GERD / reflux NONE OF THE ABOVE

Frequent daytime urination Frequent nighttime urination Recurrent UTI Recurrent yeast infection NONE OF THE ABOVE

Irregular menstrual cycles Post-menopause Difficulty with erections Difficulty conceiving Breast discharge (milky or other) NONE OF THE ABOVE

Calf cramping History of Foot ulcer Muscle aches History of fracture Swelling in legs/feet Osteopenia (low bone density) Osteoporosis NONE OF THE ABOVE

Rash Dry skin Moist skin Thick skin Easy bruising Hair loss Acne Hair growth in inappropriate places NONE OF THE ABOVE

Burning in hands/feet Numbness in hands/feet Tingling in hands/feet Tremor NONE OF THE ABOVE

Depressed mood History of Depression Anxiety History of Anxiety Jitteriness Difficulty concentrating NONE OF THE ABOVE