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ENCODRINE
Do you have type 1 diabetes?
Do you have type 2 diabetes?
Have you been told that you have prediabetes?
Do you have a history of hyperthyroidism (overactive thyroid)
Do you have a history of hypothyroidism (overactive thyroid)
Have you or anyone in your family had medullary thyroid cancer?
Do you have dry mouth?
Do you have excessive urination?
Do you have excessive thirst?
NEPHROLOGY
Have you been diagnosed with chronic kidney disease (CKD) or diabetic nephropathy?
MEN
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Have you been diagnosed with erectile dysfunction?
LUNG AND BREATHING DISORDERS
Do you have a history of asthma?
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Do you snore?
Have you been diagnosed with sleep spnea? (severe snoring)
Do you wheeze?
Do you get short breath when walking?
CARDIAC
Have you ever been diagnosed with angina?
Have you ever been diagnosed with angina?
Have you been diagnosed with congestive heart failure (CHF)?
Have you been diagnosed with heart valve disease?
Do you get short of breath when laying down?
Have you ever been diagnosed with angina?
Do your feet swell?
Have you been diagnosed with an arrhythmia (irregular heart beat)?
Have you ever been told you have a heart murmur?
Do you take medication for high cholesterol?
Do you take medication for high blood pressure?
Do you ever have chest pain?
URINARY
Do you have a history of kidney stones?
Do you have trouble holding your urine?
Do you experience excessive urination? (urinate more than normal)
At night, do you wake up to urinate?
Do you ever have blood in your urine?
CARDIAC
Do you ever have palpitations (racing heart)?
EYE
Do you have a history of glaucoma?
Do you have diabetic retinopathy (diabetes-related eye disease)?
Do you have blurry vision?

ZD#417777 Medical Form

Family Practitioner

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Published: April 23, 2019, 11:55 a.m.
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Sunnyvale, CA 94089

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