Bronson HealthCare Midwest Epic Review of Systems 10.3

Constitution Endocrine Activity Change Y N Cold intolerance Y N Appetite Change Y N Heat intolerance Y N Chills Y N Polydipsia Y N Diaphoresis Y N Polyuria Y N Fatigue Y N GU Fever Y N Difficulty urinating Y N Unexpctd wt chnge Y N Dyspareunia Y N HENT Dysuria Y N Facial Swelling Y N Enuresis Y N Neck pain Y N Flank pain Y N Neck stiffness Y N Frequency Y N Ear Discharge Y N Genital Sore Y N Hearing loss Y N Hematuria Y N Ear pain Y N Menstrual problem Y N Tinnitus Y N Pelvic pain Y N Nosebleeds Y N Urgency Y N Congestion Y N Urine decreased Y N Rhinorrhea Y N Vaginal bleeding Y N Postnasal drip Y N Vaginal discharge Y N Sneezing Y N Vaginal pain Y N Sinus Pressure Y N Musc Dental problem Y N Arthralgias Y N Drooling Y N Back pain Y N Mouth sores Y N Gait problem Y N Sore throat Y N Joint swelling Y N Trouble swallowing Y N Myalgias Y N Voice Change Y N Skin Eyes Color change Y N Eye Discharge Y N Pallor Y N Eye itching Y N Rash Y N Eye pain Y N Wound Y N Last Name: ______First Name: ______

Date of Birth: ______Today’s Date: ______Bronson HealthCare Midwest Epic Review of Systems 10.3

Eye redness Y N Allergy/Immuno Photophobia Y N Env allergies Y N Visual disturbance Y N Food Allergies Y N Respiratory Immunocompromised Y N Apnea Y N Neurological Chest tightness Y N Dizziness Y N Choking Y N Facial asymmetry Y N Cough Y N Headaches Y N Shortness of breath Y N Light-headedness Y N Stridor Y N Numbness Y N Wheezing Y N Seizures Y N Cardiovascular Speech difficulty Y N Chest pain Y N Syncope Y N Leg swelling Y N Tremors Y N Palpitations Y N Weakness Y N GI Hematologic Abd distention Y N Adenopathy Y N Abdominal pain Y N Bruises/blds easily Y N Anal bleeding Y N Psychiatric Blood in stool Y N Agitation Y N Constipation Y N Behavior problem Y N Diarrhea Y N Confusion Y N Nausea Y N Decr concentration Y N Rectal pain Y N Dysphoric mood Y N Vomiting Y N Hallucinations Y N Hyperactive Y N Nervous/Anxious Y N Self-injury Y N Sleep disturbance Y N Suicidal ideas Y N

Last Name: ______First Name: ______

Date of Birth: ______Today’s Date: ______Bronson HealthCare Midwest Epic Review of Systems 10.3

GU Difficulty urinating Y N Dysuria Y N Enuresis Flank pain Frequency Genital sore Hematuria Penile discharge Penile pain Penile swelling Scrotal swelling Testicular pain Urgency Urine decreased

Last Name: ______First Name: ______

Date of Birth: ______Today’s Date: ______Bronson HealthCare Midwest Epic Review of Systems 10.3

Last Name: ______First Name: ______

Date of Birth: ______Today’s Date: ______