Please Check All the Symptoms That Apply for the Past 3-6 Months. Patient Name

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Please Check All the Symptoms That Apply for the Past 3-6 Months. Patient Name

Review of Systems: Please check all the symptoms that apply for the past 3-6 months. Constitutional: Gastrointestinal: Dermatologic: o Loss of appetite o Blood in stool o Significant sun o Chills o Change in bowel habits exposure/sun burns o Fever o Difficulty swallowing o Change in moles o Weight gain o Abdominal pain o New skin lesions o Weight loss o Nausea o Night sweats o Vomiting Neurologic: Ophthalmologic: o Diarrhea o New headaches o Loss of vision o Constipation o Weakness on one side o Double vision o Gas and bloating o Seizures o Jaundice Ears, Nose & Throat: o Heartburn Psychological: o Nosebleed o Belching o Emotional abuse o Snoring o Stool incontinence o High stress level o Postnasal drip o Physical abuse o Hearing loss Urologic: o Sexual abuse o Voice changes o Difficulty urinating o Sleep disturbances o Blood in urine o Are you a worrier Cardiac: o Urinary urgency o Depression o Chest pain with activity o Painful urination o Do you feel anxious o Leg swelling o Frequent urination o Shortness of breath while o Recurrent urinary tract infections Endocrine: sleeping o Fatigue o Shortness of breath with Breast: o Heat intolerance activity o Breast lump o Racing heart o Chest pain o Nipple Discharge o Cold intolerance o Palpitations o Nipple inversion o Mammogram Allergy: Respiratory: o Sinus congestion o Chest pain with breathing Female Reproductive: o Stuffy nose o Shortness of breath o Sexually active o Itchy eyes o Cough o Regular periods LMP_________ o Runny nose o Wheezing o Irregular periods o Scratchy throat o Hot flashes o Decrease sex drive Hematologic\Lymphatic: Musculoskeletal: o Painful intercourse o Joint pain o Mood disturbances o Blood clots o Muscle pain o Excessive bleeding o Bone pain Male Reproductive: o Hepatitis exposure o Joint swelling o Difficulty with erection o HIV risk\exposure o Decrease sex drive o MRSA infections o Recent antibiotics o anemia o Swollen glands Patient name:___________________________________________________DOB:________________ Today’s date:____________________ .

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