Patient Sticker Review of Systems Patient Name: Date: DOB: If you have any of the following, please mark and explain below: General Chills Insomnia Fatigue Fever Weight Loss/Gain Night Sweats Specify: Head, Ears, Nose and Throat Blurred Vision Double Vision Eye Pain Light Sensitivity Head Injury Headache Nose Bleed Sinus Pain Hearing Loss Ringing in Ears Ear Drainage Sore Throat Bleeding Gums Hoarseness Specify: Cardiovascular Heart Attack Heart Failure Angina High Blood Pressure Stroke Varicose Vein or Blood Clots Heart Murmur Heart Arrhythmia Swelling in your legs or feet not caused by walking or exercise Heartburn or indigestion that is not related to eating Pain or tightness in your chest that interferes with your job Frequent pain or tightness in your chest Heart skipping or missing a beat Pain or tightness in your chest during physical activity Any other symptoms that may be related to heart or circulation problems? Specify: Respiratory Claustrophobia Asbestosis Pneumonia Broken Ribs Tuberculosis Trouble Smelling Odors Chronic Bronchitis Silicosis Asthma Emphysema Lung Cancer Wheezing Coughing up Blood Coughing that produces phlegm Pneumothorax (Collapsed Lung) Allergic reaction that interfere with your breathing Shortness of Breath Any chest injuries or surgeries Persistent/Chronic Cough Chest pain when you breathe deeply Wheezing that interferes with your job Coughing that mostly occurs when you are lying down Coughing that wakes you up early in the morning Shortness of breath that interferes with your job Shortness of breath when doing normal activities Having to stop for breath when walking at a normal pace on ground level Shortness of breath when walking fast or on level ground, hills or inclines Any other lung problems that you have been told about Specify: Gastrointestional Abdominal Pain Constipation Problems Swallowing Nausea Vomiting Blood Heartburn Ulcer Diarrhea Recurrent Vomiting Decrease Appetite Indigestion Black Bowel Movements Red or Black Rectal Bleeding Specify: Genitourinary Burning on Urination Frequent Urination Urinary Incontinence Blood in Urine Hernias Drainage from Genitals Pain in Genital Region Problems with Fertility Specify: Musculoskeletal Joint Pain Joint Stiffness Joint Swelling Gout Arthritis Fractures Night Pain Limited Motion Back Pain Specify: Skin Rash Skin Cancer Sun Sensitivity Nail Problems Changing Mole Easy Bruising Itching or Hives Acne/Eczema Specify: Neurologic/Psychiatric Uncoordination/Balance Issues Loss of Body Strength Memory Loss and Concentration Loss of Consciousness Fainting Dizziness Light Headedness Tingling Tremor Speech Deficiency Depression Stress Mood Swings Seizures Numbness Frequent Headaches Specify: Endocrine Excessive Thirst Excessive Urination Diabetes Anemia Intolerance of Hot or Cold Specify: Peripheral Vascular Leg Cramps with Exercise Blood Clots Varicose Veins Cold Feet or Hands Specify: Women Only Vaginal Discharge Abnormal Lump in Breast Irregular Monthly Menstrual Periods Abnormal Periods Recent Change or Stopping Monthly Menstrual Periods Menopause Discharge from Breast Miscarriage or Complications with Pregnancy Specify: Men Only Swelling in Scrotum Testicular Pain Lump in Testicles Specify: Negative to All Listed I certify the above responses are complete and accurate to the best of my knowledge Patient Signature Date Physician/Provider Signature Date.