Table 18.
Do you have any other diseases or health conditions diagnosed by your medical doctor? □ No. □ Yes. If yes, please tick the following listed conditions that apply to you (Please tick (✓) as many items as applicable).
| □ Cardiac | Heart problem (such as cardiopathy, pericarditis, coronary heart disease, myocarditis, angina, myocardial infarction, arrhythmia, and valve problems) |
| □ Vascular | Circulatory problem (such as peripheral atherosclerotic disease and aneurysm of the abdominal aorta), hypertension, or cholesterol problem |
| □ Hematological | Blood problem (anemia, leukemia, hypercoagulability, or any other problem affecting the blood, the blood cells, the spleen, or the lymphatic system) |
| □ Respiratory | Respiratory problem (such as asthma, emphysema, bronchitis, pulmonary embolism, or any problems related to the lungs, bronchi, and trachea) |
| □ Ophthalmological and otorhinolaryngology | Problems of the eyes (such as glaucoma, cataract, and loss of vision); ears (such as important hearing impairment and otitis media); nose (such as sinusitis and rhinitis); throat (pharyngitis), and voice |
| □ Upper gastrointestinal(does not include diabetes) | Problems of the stomach or digestion (such as problems of the esophagus, stomach, and duodenum (such as gastritis, peptic ulcer, and duodenal ulcer) |
| □ Lower gastrointestinal | Intestinal problems (such as intestinal hernias, enteritis, intestinal tuberculosis, chronic diarrhea, colitis, constipation, anal problems and bowel incontinence) |
| □ Hepatic and pancreatic | Problems of the liver (impairment in function, liver infection, etc.), pancreas (such as pancreatitis), gallbladder (such as cholecystitis) |
| □ Renal | Problems of the kidneys (impairment in function, kidney infection, etc.) |
| □ Genitourinary | Problems of the urination system, such as ureters, bladder, urethra, prostate, and genitals (such as kidney stone, urinary incontinence, bladder infection, prostate diseases, and sexual dysfunction) |
| □ Musculoskeletal-integumentary | Problems of the muscles, joints, bones, connective tissue, and skin (such as fibromyalgia, rheumatoid arthritis, osteoarthritis, osteoporosis, and other forms of arthritis, carpal tunnel syndrome, Sjogren's syndrome, systemic lupus erythematosus, polymyositis etc.) and any skin (such as atopic dermatitis, eczema, and herpes) or other musculoskeletal problems |
| □ Neurological | Neurological (brain, spinal cord, and nerves) problem (such as cerebrovascular accident, peripheral neuropathy, facial neuritis, polyneuropathy, Gearan–Kaizer syndrome, myelitis, myasthenia gravis, and multiple sclerosis) |
| □ Endocrine-metabolic | Problems of the thyroid gland, obesity, diabetes, or any other hormonal problems |
| □ Psychiatric | Problems of depression, anxiety, alcohol, drug abuse, or other problems |
| □ Female hormonal and reproductive (for females only) | Problems of reproductive system (such as the uterus, ovary, and fallopian tubes) and other gynaecological problems (such as premenstrual syndrome, polycystic ovary syndrome, and pelvic inflammatory disease) |
| □ Others (please specify) | |