a. Cough

YES, TWO WEEKS OR LONGER 1
YES, LESS THAN TWO WEEKS 2
NO 3

b. Fever

YES, ONE MONTH OR LONGER 1
YES, LESS THAN ONE MONTH 2
NO 3

c. Drenching night sweats

YES, ONE MONTH OR LONGER 1
YES, LESS THAN ONE MONTH 2
NO 3

d. Unexpected weight lost

YES, ONE MONTH OR LONGER 1
YES, LESS THAN ONE MONTH 2
NO 3

e. General fatigue or malaise

YES, ONE MONTH OR LONGER 1
YES, LESS THAN ONE MONTH 2
NO 3

f. Chest pain

YES, ONE MONTH OR LONGER 1
YES, LESS THAN ONE MONTH 2
NO 3

BACK PAIN A
NECK OR SHOULDER PAIN B
HEADACHE, FACIAL OR DENTAL PAIN C
STOMACH ACHE OR ABDOMINAL PAIN D
PAIN IN ARMS, HANDS, HIPS, LEGS OR FEET E
CHEST PAIN F
OTHER (SPECIFY) __________ X