Question post text
1 COMMUNICABLE DISEASE (INFECTIONS, MALARIA, TUBERCULOSIS, HIV)
2 MATERNAL AND PERINATAL CONDITIONS (PREGNANCY)
3 NUTRITIONAL DEFICIENCIES
4 ACUTE CONDITIONS (DIARRHEA, FEVER, FLU, HEADACHES, COUGH, OTHER)
5 INJURY (NOT WORK RELATED, SEE 8 BELOW)
6 SURGERY
7 SLEEP PROBLEMS
8 OCCUPATION / WORK RELATED CONDITION/INJURY
9 CHRONIC PAIN IN [NAME'S] JOINTS/ARTHRITIS (JOINTS, BACK, NECK)
10 DIABETES OR RELATED COMPLICATIONS 11 PROBLEMS WITH [NAME'S] HEART INCLUDING UNEXPLAINED PAIN IN CHEST
12 PROBLEMS WITH [NAME'S] MOUTH, TEETH OR SWALLOWING
13 PROBLEMS WITH [NAME'S] BREATHING
14 HIGH BLOOD PRESSURE / HYPERTENSION
15 STROKE/SUDDEN PARALYSIS OF ONE SIDE OF BODY
16 GENERALIZED PAIN (STOMACH, MUSCLE OR OTHER NONSPECIFIC PAIN)
17 DEPRESSION OR ANXIETY
18 CANCER
87 OTHER, SPECIFY: