General • Fever • Chills • Weight Loss • Weight Gain • Night Swea

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General • Fever • Chills • Weight Loss • Weight Gain • Night Swea

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 .

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