New Patient Review of Systems

New Patient Review of Systems
Patient Name *
Date of Birth *

Month Day Year
Date
Today's Date *

Month Day Year
Date
ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING:
General
Good general health lately

no yes
Recent weight change

no yes
Fever

no yes
Fatigue

no yes
Eyes and Vision
Eye disease or injury

no yes
Blurred or double vision

no yes
Glaucoma

no yes
Ears, nose, throat and mouth
Hearing loss

no yes
Ringing in the ears

no yes
Earaches

no yes
Sinus problems

no yes
Mouth sores

no yes
Dental or chewing problems

no yes
Dentures

no yes
Heart trouble
Heart trouble

no yes
Chest pains

no yes
Sudden heartbeat changes

no yes
Swelling of feet, ankles, hands

no yes
Breathing trouble
Frequent coughing

no yes
Spitting up blood

no yes
Shortness of breath

no yes
Asthma or wheezing

no yes
Stomach trouble
Loss of appetite

no yes
Change in bowel movements

no yes
Nausea or vomiting

no yes
Stomach pain

no yes
Gastric Bypass or Lap Band

no yes
Joint trouble
Cold hands / feet

no yes
Difficulty walking

no yes
Muscle pain or cramps

no yes
Neurologic trouble
Frequent or recurrent headaches

no yes
Light headed or dizzy

no yes
Convulsions or seizures

no yes
Numbness or tingling sensations

no yes
Tremors or shaking

no yes
Involuntary movements

no yes
Stroke

no yes
Head injury

no yes
Balance problems

no yes
Hormone trouble
Thyroid disease

no yes
Diabetes

no yes
Excessive thirst or urination

no yes
Heat or cold intolerance

no yes
Change in hat or glove size

no yes
Change in skin color

no yes
Change in hair or nails

no yes
Bleeding trouble
Slow to heal after cuts

no yes
Easily bruising or bleeding

no yes
Anemia

no yes
Urination trouble
Frequent urination

no yes
Burning or painful urination

no yes
Blood in urine

no yes
Activity (Check one or more boxes)

Occasional vigorous activity Regular vigorous exercise
Women
Last Menstrual Period
Any menstrual problems?

no yes
Number of pregnancies
Difficult pregnancy?

no yes
Miscarriages?
Birth control method (if any)?
Hysterectomy?

no yes
Breast pain / lump / discharge?

no yes
Last mammogram?
Men
Prostate problems?

no yes
Erectile problems?

no yes
Vasectomy?

no yes
Hormone Irregularities?

no yes
Patient / Guardian Signature

Clear
Date

Month Day Year
Date
Should be Empty: