• Patient Review of Systems

  • Date of Birth*
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  • Today's Date*
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  • ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING:

  • General
  • Good general health lately
  • Recent weight change
  • Fever
  • Fatigue

  • Eyes and Vision

  • Eye disease or injury
  • Blurred or double vision
  • Glaucoma
  • Ears, nose, throat and mouth
  • Hearing loss
  • Ringing in the ears
  • Earaches
  • Sinus problems
  • Mouth sores
  • Dental or chewing problems
  • Dentures

  • Heart trouble

  • Heart trouble
  • Chest pains
  • Sudden heartbeat changes
  • Swelling of feet, ankles, hands

  • Breathing trouble

  • Frequent coughing
  • Spitting up blood
  • Shortness of breath
  • Asthma or wheezing

  • Stomach trouble

  • Loss of appetite
  • Change in bowel movements
  • Nausea or vomiting
  • Stomach pain
  • Gastric Bypass or Lap Band
  • Joint trouble
  • Cold hands / feet
  • Difficulty walking
  • Muscle pain or cramps

  • Neurologic trouble

  • Frequent or recurrent headaches
  • Light headed or dizzy
  • Convulsions or seizures
  • Numbness or tingling sensations
  • Tremors or shaking
  • Involuntary movements
  • Stroke
  • Head injury
  • Balance problems

  • Hormone trouble

  • Thyroid disease
  • Diabetes
  • Excessive thirst or urination
  • Heat or cold intolerance
  • Change in hat or glove size
  • Change in skin color
  • Change in hair or nails

  • Bleeding trouble

  • Slow to heal after cuts
  • Easily bruising or bleeding
  • Anemia

  • Urination trouble

  • Frequent urination
  • Burning or painful urination
  • Blood in urine
  • Activity (Check one or more boxes)

  • Women

  • Any menstrual problems?
  • Difficult pregnancy?
  • Hysterectomy?
  • Breast pain / lump / discharge?

  • Men

  • Prostate problems?
  • Erectile problems?
  • Vasectomy?
  • Hormone Irregularities?
  • Date
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  • Should be Empty: