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Welcome to Your Daily Health Check

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What is your gender?

Male
Female
Other

What is your age?

Do you experience pain?

Yes
No

Where on your body do you feel pain?

How would you rate your pain on a scale from 1 to 10, with 1 being mild and 10 being severe?

1 2 3 4 5 6 7 8 9 10
5

How often do you experience pain throughout the day?

Are there specific activities or times when the pain worsens?

Have you experienced any fever?

Yes
No

If yes, what was your highest recorded body temperature?

Do you experience fatigue?

Yes
No

How would you rate your level of fatigue on a scale from 1 to 10, with 1 being fully energized and 10 being completely exhausted?

1 2 3 4 5 6 7 8 9 10
5

How does fatigue affect your daily activities?

How would you rate your appetite on a scale from 1 to 10, with 1 being no appetite and 10 being very hungry?

1 2 3 4 5 6 7 8 9 10
5

Have you noticed any changes in your eating habits?

Yes
No

What changes have you noticed in your eating habits?

How would you rate your sleep quality on a scale from 1 to 10, with 1 being very poor and 10 being excellent?

1 2 3 4 5 6 7 8 9 10
5

Do you have trouble falling asleep or staying asleep?

Yes
No

Do you experience breathing difficulties?

Yes
No

How would you rate your breathing difficulty on a scale from 1 to 10, with 1 being no difficulty and 10 being severe shortness of breath?

1 2 3 4 5 6 7 8 9 10
5

When do you experience shortness of breath?

During physical activity
At rest
Both
None

Do you experience nausea?

Yes
No

How would you rate your nausea on a scale from 1 to 10, with 1 being no nausea and 10 being severe nausea?

1 2 3 4 5 6 7 8 9 10
5

Have you experienced vomiting or dry heaves?

Yes
No

If yes, how often does this occur?

Do you have a cough?

Yes
No

How would you rate the severity of your cough on a scale from 1 to 10, with 1 being no cough and 10 being a severe, persistent cough?

1 2 3 4 5 6 7 8 9 10
5

Is your cough productive (with mucus) or dry?

Productive (with mucus)
Dry

Do you have a rash or itching?

Yes
No

How would you rate the severity of your rash or itching on a scale from 1 to 10, with 1 being mild and 10 being severe?

1 2 3 4 5 6 7 8 9 10
5

Is the rash localized or widespread?

Localized
Widespread

If localized, where is the rash located?

Do you experience swelling?

Yes
No

How would you rate the swelling on a scale from 1 to 10, with 1 being mild and 10 being severe?

1 2 3 4 5 6 7 8 9 10
5

Is the swelling accompanied by redness or warmth?

Do you experience slow movements or difficulty initiating movements?

Yes
No

How would you rate the severity of this symptom on a scale from 1 to 10, with 1 being mild and 10 being severe?

1 2 3 4 5 6 7 8 9 10
5

Have you noticed tremors or stiffness in your body?

Yes
No

Where on your body do you experience these symptoms?

Have you experienced diarrhea?

Yes
No

If yes, how would you describe the consistency and frequency of your stools?

Are there any other health concerns you'd like to mention?

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