This form is a document that helps medical practitioners determine the cause of a patient's symptoms.This form allow physicians to run through a series of statements, checking “yes” or “no” to determine what could be causing a patient’s symptoms.The form can be used to determine if a patient is experiencing symptoms of a disease or condition, such as a disease of the brain, colon, heart, lungs, kidneys, or liver. Collect patient information and determine whether they are experiencing symptoms related to a disease or condition with this form.