REVIEW OF SYSTEMS MAT-SU HEALTH SERVICES, INC. Adult

Name: ______Date of Birth: ______

Constitutional HEENT Respiratory Chills Ear discharge Chronic cough Fatigue/tired Ear Pain Cough Fever Visual Changes Known TB exposure Lethargy Eye Pain Shortness of breath Malaise (body Weakness) Hearing Loss Wheezing Night sweats Nasal drainage Other: Weight gain Sinus Pressure Weight loss Sore Throat Other: Other:

Cardiovascular Gastrointestinal Genitourinary Chest Pain Abdominal pain Dysuria (painful urination) Claudication (cramping pain in legs) Blood in stools Hematuria (blood in urine) Edema (swelling in extremeties) Change in stools Polyuria (excessive urination) Palpatations Constipation Frequent urination Other: Diarrhea Urinary incontinence Heartburn Urinary retention Loss of appetite Other: Nausea Vomiting Other:

Reproductive (female) Integumentary Neurological Abnormal PAP Breast discharge Dizziness Dysmenorrhea(menstraul cramps) Breast lump Extremity numbness Dyspareunia (painful intercourse) Brittle hair Extremity weakness Hot flashes Brittle nails Gait disturbance Irregular menses Hair loss Headache Vaginal discharge Hirsutism( male hair growth) Memory loss Other: Hives Seizures Pruritis Tremors Reproductive (male) Mole changes Other: Erectile dysfunction Rash Penile discharge Skin lesion Sexual dysfunction Other: Other:

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Review of Systems Adult 8/16/16 Psychiatric Metabolic/ Endocrine Musculoskeletal Anxiety Cold intolerance Back pain Depression Heat intolerance Joint Pain Insomnia Polydipsia Joint swelling Other: Polyphagia Muscle weakness Other: Neck pain Other:

Hematologic/ Lymphatic Immunologic Easy bleeding Contact allergy Easy bruising Environmental allergies Lymphadenopathy(abnormal lymph nodes) Food allergies Other: Seasonal allergies Other: