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Review of Systems

Consititutional System

Good Genral Health
Yes No
Recent Weight Change
Yes No
Fever
Yes No
Fatigue
Yes No
Headaches
Yes No

EYES

Eye Disease or Injury
Yes No
Wear Glasses/Contact Lenses
Yes No
Blurred or Double Vision
Yes No
Glaucoma
Yes No

EARS/NOSE/THROAT

Hearing Loss/Ringing
Yes No
Chronic Sinus Problems
Yes No
Nose Bleeds
Yes No
Bad Breath or Bad Taste
Yes No
Sore Throat/Voice Change
Yes No

CARDIOVASCULAR

Heart Problems
Yes No
Chest Pain or Angina
Yes No
Palpitations
Yes No
Shortness or Breath Lying
Yes No
Swelling of Feet/Ankles/Hands
Yes No
Varicose Veins
Yes No

RESPIRATORY

Chronic Coughing
Yes No
Coughing up Blood
Yes No
Shortness of Breath
Yes No
Astham or Wheezing
Yes No

MUSKULOSKELETAL

Joint Pain/Stiffness/Swelling
Yes No
Weakness in Muscles/Joints
Yes No
Muscle Pain or Cramps
Yes No
Cold Extremities
Yes No
Difficulty Walking
Yes No

GASTROINTESTINAL

Loss of Appetite
Yes No
Change in Bowel Movements
Yes No
Painful Bowel Movements
Yes No
Constipation
Yes No
Rectal Bleeding/Blood in Stool
Yes No
Abdomial Pain/Heartburn
Yes No
Peptic Ulcer
Yes No
Unable to Restrain Stools
Yes No
Colon Cancer
Yes No
Polyps
Yes No
Nausea or Vomitting
Yes No

Have you ever following tests

Colonoscopy
Yes No
Barium Enema
Yes No
Flexible Sigmoidoscopy
Yes No

BLOOD AND LYMPH

Slow to Heal After Cuts
Yes No
Bleeding/Bruising Tendency
Yes No
Anemia
Yes No
Blood Clots
Yes No
Past Transfusion
Yes No
Enlarged Glands
Yes No

URINARY AND REPRODUCTIVE

Frequent Urination
Yes No
Burning Painful/Urination
Yes No
Blood in Urine
Yes No
Unable to Restrain Dribbling
Yes No
Kidney Stones
Yes No
Male-Testicle Pain
Yes No
Female Pain with Periods
Yes No
Female Irregular Periods
Yes No
Female Vaginal Discharge
Yes No
Female Breast Feed
Yes No
Female Hysterectomy
Yes No
Female Ovaries Removed
Yes No
Female Birth Control
Yes No
Female Age Started Periods
Yes No
Female Last Menstrual Period(date)
Female- # of Pregnancies
Female- # of Miscarriages
Female- # Age of First Pregnancy
Female- # of Children
Female- Date of Last Pap Smear

SKIN AND BREAST

Rash and Itching
Yes No
Breast Pain or Soreness
Yes No
Breast Lump
Yes No
Had Recent Mammogram
Yes No
Any Previous Breast Surgery
Yes No

NEUROLOGICAL

Frequent Headaches
Yes No
Light Headedness or Dizziness
Yes No
Convulsions or Seizures
Yes No
Numbness/Tingling
Yes No
Tremors
Yes No
Paralysis
Yes No
Stroke
Yes No
Head Injury
Yes No

ENDOCRINE

Gland/Hormone Problem
Yes No
Thyroid Disease
Yes No
Diabetes
Yes No
Excessive Thirst/Urination
Yes No
Heat or Cold Intolerence
Yes No
Skin Becoming Dryer
Yes No

PSYCHIATRIC

Memory Loss/Confusion
Yes No
Nervousness
Yes No
Depression
Yes No
Problems Sleeping
Yes No