spierschiropractic.com - Review Of Patient Systems

Review Of Patient Systems
Patient Name
Date

MonthDayYear
Date
INSTRUCTIONS: Please select all that apply. If none of the conditions apply in a section, select "None."
Constitutional

NoneChillsDaytimeDrowsinessFatigueFeverNight SweatsWeight GainWeight Loss
Eyes/Vision

NoneBlindnessBlurred VisionCataractsChange in VisionDouble VisionEye PainField CutsGlaucomaItching (around the eyes)PhotophobiaTearingWears Glasses or Contacts
Ears, Nose and Throat

NoneDental ImplantsDenturesDifficulty SwallowingDischargeDizzinessEar DrainageEar Infection(s)Ear PainFaintingHeadachesHead Injury (history of)Hearing LossHoarsenessLoss of SmellNasal CongestionNose BleedsPost Nasal DripRhinorrhea (runny nose)Sinus InfectionsSnoringSore ThroatsTinnitus (ringing in the ears)TMJ Disorder
Cardiovascular

NoneAngina (chest pain or discomfort)Chest PainClaudication (leg pain or achiness)Heart MurmurHeart ProblemsOrthopnea (difficulty breathing while lying)Palpitations (irregular or forceful heart beat)Paroxysmal Nocturnal Dyspnea (shortness of breath at night)Shortness of BreathSwelling of Leg(s)UlcersVaricose Veins
Gastrointestinal

NoneAbdominal PainBelchingBlack, Tarry StoolsConstipationDiarrheaDifficulty SwallowingHeartburnHemorrhoidsIndigestionJaundice (yellowing of the skin)NauseaRectal BleedingAbnormal Stool Caliber (quality)Abnormal Stool ColorAbnormal Stool ConsistencyVomitingVomiting Blood
Respiration

NoneAsthmaCoughing up bloodShortness of BreathSputum ProductionWheezing
Endocrine

NoneCold IntoleranceDiabetesExcessive AppetiteExcessive HungerExcessive ThirstFrequent UrinationGoiterHair LossHeat IntoleranceUnusual Hair GrowthVoice Changes
Skin

NoneChanges in Nail TextureChanges in Skin ColorHair GrowthHair LossHivesItchingParesthesia (numbness, prickling, or tingling)RashHistory of Skin DisordersSkin Lesions or UlcersVaricosities
Nervous System

NoneDizzinessFacial WeaknessHeadachesLimb WeaknessLoss of ConsciousnessLoss of MemoryNumbnessSeizuresSleep DisturbanceSlurred SpeechStressStrokesTremorsUnsteadiness of Gait
Allergy

NoneAnaphylaxis (history of)Food IntoleranceItchingNasal CongestionSneezing
Hematology

NoneAnemiaBleedingBlood ClottingBlood Transfusion(s)Bruises easilyFatigueLymph Node Swelling
Psychological

NoneAnhedonia (inability to experience joy or enjoy life)AnxietyAppetite ChangesBehavioral Change(s)Bipolar DisorderConfusion ConvulsionsDepression InsomniaMemory LossMood Change(s)
Female

NoneBirth Control TherapyBreast Lumps / PainBurning UrinationCrampsFrequent UrinationHormone TherapyIrregular MenstruationUrine RetentionVaginal BleedingVaginal Discharge
Male

NoneBurning UrinationErectile DysfunctionFrequent UrinationHesitancy or DribblingProstate ProblemsUrine Retention
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