SYMPTOMS: REPRODUCTIVE
Some of the questions below are personal in nature. If you are unwilling to answer a question, skip it by leaving the default "don't know" response. |
| 541. |
At what age did you become sexually active? |
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| 542. |
What is the approximate number of sexual partners that you have had during your lifetime? |
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| 543. |
Is your sexual desire (libido)... ? |
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| 544. |
Have you had endometriosis? |
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| 545. |
Have you had Pap smear tests? |
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| 546. |
Cervical Dysplasia. Have irregular, but non-cancerous, cells been found on a PAP smear? (Class 1 = Slightly abnormal, Class 2 = Abnormal, Class 3 = Severely abnormal. Class 4 would be cancer.) |
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| 547. |
Do you have difficulty achieving an orgasm? |
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| 548. |
When you have tried, how difficult in general has it been for you to conceive children? |
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| 549. |
Is there a chance of your becoming pregnant within the next six months? |
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| 550. |
Have you ever been pregnant, now or in the past? |
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| 551. |
Have you had uterine fibroids? |
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| 552. |
Have you had ovarian cysts? |
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| 553. |
Do you find that deep penetration during sexual intercourse is particularly painful? |
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| 554. |
Do you ever experience a vaginal burning sensation? |
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| 555. |
Do you have any unusual vaginal discharge or bleeding? An unusual discharge may be heavier/thicker than usual, puslike, grayish, greenish, yellowish, blood-tinged, foul-smelling, with possible itching/burning/rash/soreness. |
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| 556. |
Do you have vaginal itching? |
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| 557. |
Do you experience any discomfort in the vulvar area (labia and opening to the vagina)? |
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| 558. |
Do you experience vaginal dryness? It is usually associated with itching, burning and pain during sexual intercourse. |
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| 559. |
Do you have any genital sores or lesions? |
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| 560. |
Do you have any wart-like fleshy bumps in or around the vagina or anus, or groin? They may bleed when irritated, and may occur individually or merge to form small cauliflower-like clusters. |
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| 561. |
What is your current menstrual status? If unsure, answer Premenopausal if aged under 45 or Perimenopausal if 45-52. Only answer Postmenopausal if you have passed through menopause. Answering Don't know will present all menstrual questions. |
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| 562. |
What is your HIV/AIDS risk/status? |
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| 563. |
Other than AIDS, have you had any form of sexually-transmitted disease (STD)? |
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Add any additional information here for the questions above:
Please mention the question number(s) if possible.
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| SYMPTOMS: RESPIRATORY |
| 564. |
Do you have a cough that produces mucus? |
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| 565. |
Do you have a cough that does not produce mucus (a 'dry cough')? |
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| 566. |
Do you have Chronic Obstructive Pulmonary Disease (COPD), also known as Emphysema or chronic Bronchitis? |
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| 567. |
Do you have a history of Acute Infectious Bronchitis? Symptoms may include chest pain on coughing, difficulty breathing, mild fever and a cough with mucus produced later in the course of the infection. |
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| 568. |
Do you feel worse when in moldy or musty places? |
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| 569. |
Pneumonia |
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| 570. |
Do you ever have shortness of breath that is not associated with significant exertion? In other words, do you experience a sensation of difficult or uncomfortable breathing or a feeling of not getting enough air? |
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| 571. |
How easily do you become short of breath? |
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| 572. |
Asthma |
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| 573. |
Do you wheeze? If you are using respiratory medication (e.g. for asthma), tell us if you wheeze when you are not using it. |
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| 574. |
Sore throat / tonsillitis. How many times per year do you suffer from this? |
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| 575. |
Tuberculosis |
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| 576. |
Have you experienced any kind of chest pain, burning, tightness, pressure or discomfort within the past year? |
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Add any additional information here for the questions above:
Please mention the question number(s) if possible.
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| SYMPTOMS: SLEEP |
| 577. |
How often do you take a nap outside of normal sleeping hours? |
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| 578. |
Roughly how often do you yawn, on average? |
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| 579. |
Drowsiness. Not including after meals, do you find yourself often falling asleep in situations such as boring meetings, watching TV or while driving? |
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| 580. |
Do you generally become sleepy after eating? |
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| 581. |
Do you have difficulty staying awake after midnight? |
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| 582. |
How is your quality of sleep when you are able to sleep without interruption or pain? |
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| 583. |
Sleep. On average, how many hours of sleep do you get per night? |
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| 584. |
Do you sweat at night? Only include sweating that is not the result of an overly warm environment or too many bed covers. |
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| 585. |
If you suffer from night sweats (severe/drenching sweating that is not due to heat or humidity), for how long has it been a problem? |
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| 586. |
Do you experience bizarre, vivid or nightmarish dreams? |
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| 587. |
Do you remember your dreams when you wake up? |
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| 588. |
Do you have any other sleep problems? Examples include insomnia, restless legs, snoring, apnea, other sleep disorders, grogginess and problems that are present upon waking up. |
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Add any additional information here for the questions above:
Please mention the question number(s) if possible.
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| SYMPTOMS: CARDIOVASCULAR |
| 589. |
Atherosclerosis. |
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| 590. |
Have you had an enlarged artery called an aneurysm or experienced a ruptured aneurysm? Sometimes cerebral aneurysms are the cause of stroke, although most strokes are caused by clotting rather than by a rupturing aneurysm. |
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| 591. |
Do you have Raynaud's phenomenon (extreme loss of circulation to fingers and/or toes)? |
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| 592. |
Have you been diagnosed with vasculitis? |
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| 593. |
Have you been diagnosed with phlebitis or thrombophlebitis? |
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| 594. |
Do you suffer from occasional and unusual pain that is in your chest, upper left arm, or left side of neck? |
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| 595. |
Does your heart sometimes race or palpitate such that you can feel it beating? |
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| 596. |
Have you had any kind of heart problem not mentioned above? Examples include heart attack, valve damage, enlargement, weakness, failure, pain, etc. |
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| 597. |
Do you have varicose veins? |
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| 598. |
Have you had any kind of anemia? |
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Add any additional information here for the questions above:
Please mention the question number(s) if possible.
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| SYMPTOMS: IMMUNE SYSTEM |
| 599. |
Have you suffered from boils, abscesses or carbuncles? |
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| 600. |
Have you ever been diagnosed with cytomegalovirus (CMV)? |
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| 601. |
Have you ever been diagnosed with Epstein-Barr virus (EBV)? |
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| 602. |
Have you had vaginal yeast infections? Symptoms may include itching, burning or a "cottage cheese" discharge. |
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| 603. |
Have you been diagnosed with Candida infection anywhere in your body other than the vagina? |
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| 604. |
Have you had vaginal infections that were NOT caused by yeast? Symptoms, if any, may include discharge, irritation and itching. |
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| 605. |
Have you had fungal or yeast infections anywhere OTHER THAN the vagina? |
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| 606. |
Have you had Coccidioidomycosis (Valley Fever)? |
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| 607. |
Do you have a history of infections, for example skin, ear, bladder, respiratory etc.? |
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| 608. |
Have you ever been diagnosed with Lupus (SLE, Systemic Lupus Erythromatosis)? |
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| 609. |
Have you ever been diagnosed with Lyme disease? |
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| 610. |
Do you generally have poor wound healing? |
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| 611. |
Blood clotting problems. When you start to bleed, does it take a long time to stop? |
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| 612. |
Have you suffered from Postviral Syndrome - a viral infection where symptoms persist for a long time? |
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| 613. |
Have you been diagnosed with scleroderma? |
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| 614. |
Have you had Shingles, also known as Varicella Zoster? |
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| 615. |
Have you been diagnosed with chronic thyroiditis (Hashimoto's disease)? |
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| 616. |
Have you had tumors that were benign, or non-ovarian cysts? |
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| 617. |
Do you have Multiple Sclerosis? Details can be entered into box below. |
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| 618. |
Have you ever had from any form of cancer? |
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Add any additional information here for the questions above:
Please mention the question number(s) if possible.
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