Review of Systems (circle any symptoms you have)

General  Dry eyes  Awakened by shortness of  Fever  Sandy, gritty sensation in eyes breath  Chills Ears  Leg/ankle swelling  Weight Loss  Hearing loss  Color changes in legs/feet  Weight Gain  Earache  Leg cramps with walking  Night Sweats  Ear pain  Heart murmur  Fatigue  Swollen ear GI/Abdomen  Weakness  Red ear  Abdominal pain Endocrine  Floppy ear  Heartburn  Cold intolerance  Ringing in ears  Nausea  Heat intolerance  Drainage from ear  Vomiting  Excessive thirst  Vertigo  Difficulty swallowing  Excessive urination Nose  Diarrhea  Excessive sweating  Runny nose  Constipation  Flushing  Nasal congestion  Blood in stools Skin  Nose bleeds  Black, sticky stools  Rash/purple or red  Deformity of nose  Mucous in stools spots/pigment change  Swelling of nose  Jaundice  Hair loss  Red nose  History of food poisoning  Sun sensitivity  Dry nose Genitourinary/Urology  Hives  Nose sores  Pain/burning with urination  Thickening or tightening of  Loss of sense of smell  Difficulty urinating skin  Sinusitis  Urinary incontinence  Calcium deposits Mouth  Cloudy urine  Fingers/toes turn colors in the  Sores in mouth  Blood in urine cold  Dry mouth  History of STDs  Nodules  Dental problems Women only  Psoriasis  Loss of taste  Pre-eclampsia or high blood  Nail problems  Difficulty swallowing pressure during pregnancy  Dry skin  Bleeding gums  History of miscarriage Neurologic  Sore throat  Vaginal discharge  Migraines  Hoarseness/change in voice  Vaginal ulcers  Headaches Allergy Men only  Numbness/tingling  Frequent sneezing  Penile discharge  Muscle weakness  Seasonal allergies  Penile ulcers  Incontinence  Increased infections  Prostate trouble  Seizures Lungs Blood/Lymph  Muscle cramps  Shortness of breath  Swollen lymph nodes (status  Difficulty thinking or  Cough post biopsy) remembering  Coughing up blood  Blood clots Scalp/Head  Wheezing  Bleeding tendency  Hair loss  Chest pain with  Bruising  Scalp tenderness breathing/pleurisy  Transfusions  Headache Heart Psychology  Jaw pain with chewing  Chest pain  Depression Eyes  Stabbing chest  Anxiety/Panic Attacks  Vision problems pain/pericarditis  Insomnia or Disturbed sleep  Double Vision  Irregular or rapid heart rate  Wake up unrefreshed  Red eye or pink eye  Lightheadedness/Passing out  High stress level  History of pink eye as an  Sleep on more than 2 pillows adult due to shortness of breath  Eye Pain