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SREENING & VITAL SIGNS

I. REVIEW OF SYSTEMS

2. Do you experience any of the following: fever, cough, colds, or headache?
3. Do you experience any of the following: unexplained change in weight, loss of appetite, change in bowel movement, or abdominal pain?
4. Do you experience any of the following: chest pain or difficulty in breathing?
5. Do you experience any of the following: frequent urination, frequent eating, frequent intake of fluids, smoking and drinking alcohol?
6. Do you experience any of the following: pain or discomfort on urination or frequency of urination?

If the answer is yes to Questions 1-6, the beneficiary needs to consult a doctor.

II. PERTINENT PHYSICAL EXAMINATION FINDINGS

General Survey:
Blood Type (as available)

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