Review of Systems

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Personal Information





 








 

Are You Currently Or Do You Regularly Experience: *

Please check yes or no. Do not leave any item blank.
 

Constitutional

 
  Weight Loss Yes No Fatigue Yes No
  Fever Yes No    
 
         

Eyes

 
  Blurred Vision Yes No Double Vision Yes No
  Eye Pain Yes No    
 
         

Ears

 
  Ringing in Ears Yes No Vertigo/Dizziness Yes No
  Hearing Loss Yes No Ear Pain Yes No
  Itching In Ear Yes No Roaring Sound Yes No
  Ear Discharge Yes No Ear Fullness Yes No
  Pressure Sensation Yes No    
 
         

Nose

 
  Nasal Obstruction Yes No Nasal Pain Yes No
  Decreased Sense of Smell Yes No Nose Bleeding Yes No
  Nasal Discharge Yes No Postnasal Drip Yes No
  Nasal Congestion Yes No Snoring Yes No
 
         

Throat, Mouth & Sinus

 
  Sore Throat Yes No Swollen Glands Yes No
  Difficulty Swallowing Yes No Change In Voice Yes No
  Hoarseness Yes No Lump In Throat Sensation Yes No
  Neck Tenderness Yes No Mouth Pain Yes No
  Frequently Throat Clearing Yes No Dentures Yes No
  Sinus Pain Yes No Headaches Yes No
 
         

Cardiovascular

 
  Chest Pain Yes No Palpitations Yes No
  High Blood Pressure Yes No    
 
         

Respiratory (Lungs)

 
  Shortness of Breath Yes No Wheezing Yes No
  Cough Yes No Coughing Blood Yes No
 
         

Gastrointestinal (Stomach)

 
  Nausea Yes No Vomiting Yes No
  Difficulty Swallowing Yes No Painful Swallowing Yes No
  Excessive Belching Yes No Heartburn/Acid Reflux Yes No
 
         

Genitourinary

 
  Urgency Yes No Frequency Yes No
  Pain When Urinating Yes No    
 
         

Integumentary (Skin)

 
  New Skin Lesions Yes No Pigmentation Changes Yes No
  Changes to Existing Lesions Yes No    
 
         

Neurological (Nerves)

 
  Tremors Yes No Seizures Yes No
  Loss of Balance Yes No Tingling or Numbness Yes No
 
         

Musculoskeletal

 
  Joint Pain Yes No Joint Swelling Yes No
  Muscle Pain Yes No    
 
         

Endocrine

 
  Cold Intolerance Yes No Heat Intolerance Yes No
  Loss of Hair Yes No Weight Loss Yes No
  Weight Gain Yes No Hot Flashes Yes No
 
         

Psychiatric

 
  Anxiety Yes No Depression Yes No
  Difficulty Sleeping Yes No    
 
         

Hematologic/Lymph Nodes

 
  Easy Bleeding Yes No Easy Bruising Yes No
  Enlargement or Tenderness Yes No    
 
         

Allergic/Immunologic

 
  Reaction to Anesthesia Yes No Sneezing Yes No
  Itchy Watery Burning Eyes Yes No    
 

* Required Fields