HYBRID MEDICAL SOLUTION REVIEW OF SYSTEMS
Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Today's Date
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Month
-
Day
Year
Date
PLEASE CHECK ALL OF THE COMPLAINTS YOU HAVE DURING TODAY’S VISIT
General
Fever
Chills
Weakness
Weight Gain
Weight Loss
Dizziness
Passing out
Head
Headaches
Sinus Pressure
Head Injury
Hair Loss
EYES
Blurred Vision
Change In Vision
Double Vision
Eye Pain
Redness
Excessive Tearing
Yellow Eyes
Ears
Hearing Loss
Ear Pain
Ringin In The Ears
Use Of Hearing Aids
Nose
Runny Nose
Nose Blends
Sneezing
Nasal Congestion
Mouth
Use Of Dentures
Mouth Pain
Mouth Sores
Dental Problems
Gum Bleeding
Tongue Changes
Burning Mouth
Throat
Sore Throat
Hoarse Voice
Difficulty Swallowing
Snoring
Neck
Neck Pain
neck Stiffness
Neck Tenderness
Swollen Glands
Enlarged Thyroid
Chest
Chest Pain
Shortness of Breath
Palpitations
Racing Heart
Cough
Wheezing
Breast
Breast Lump(s)
Breast Tenderness
Breast Swelling
Breast Redness
Breast Discharge
Nipple Pain
Abdomen
Abdominial Pain
Nausea
Vomitting
Diarrhea
Constipation
Loss of Appetite
Bloating
Excessove Gas
Excessive Belching
Hernia
Rectum
Hemorrhoids
Blood On Toilet Paper
Blood In Stool
Rectal Itching
Rectal Pain
Stool Incontinence
Urinary
Urinary Urgency
Frequent Urination
Burning With Urination
Urine Color Change
Urine Odor Change
Female Genital
Change In Menstruation
Pain With Intercourse
Abnormal Bleeding
Abnormal Discharge
Vaginal Dryness
Type option 3
Type option 4
Male Genital
Erectile Dysfunction
Penile Sores
Decreased Libido
Testicular Pain
Testicular Lumps
Penile Discharge
Back
Upper Back Pain
Lower Back Pain
Middle Back Pain
Buttock Pain
EXTREMITIES
Muscle Pain
Muscle Cramps
Joint Pain
Bone Pain
Calf Pain
Ankle Pain
NEUROLOGICAL
Weakness
Numbness
Tremor
Seizures
Memory Loss
Difficulty Walking
Mental Health
Depression
Anixety
Difficulty Sleeping
Suicidal Thoughts
Hallucinations
Agitation
Hostility
Hyperactivity
Concentration Problems
Skin
Rash
Suspicious Moles
Itching
Dry Skin
Nail Changes
Acne
List Any Other Concerns
WHAT OTHER ISSUES WOULD YOU LIKE TO DISCUSS WITH THE PROVIDER?
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