Review Of Systems
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Patient Information
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
* Required Information
Review of Systems
Please mark only the symptoms you are CURRENTLY experiencing.
Mark all that apply. If no symptoms, please mark "NONE."
*
General
Chills
Weight loss
Night sweats
Fever
Weight gain
Appetite loss
Excessive perspiration
Feeling sick
Fatigue
None
*
Eyes
Double vision
"Halos" around lights
Discharge
Vision loss - one eye
Blurring
Eye irritation
Vision loss - both eyes
Light sensitivity
Eye pain
None
*
Ear, Nose, and Throat
Earache
Ringing in ears
Ear discharge
Nosebleeds
Hoarseness
Decreased hearing
Nasal congestion
Sore throat
None
*
Cardiovascular
Shortness of breath with exertion
Swelling of hands or feet
Leg cramps with exertion
Bluish discoloration of lips or nails
Chest pain or discomfort
Difficulty breathing lying down
Racing / Skipping heartbeats
None
*
Respiratory
Excessive sputum
Cough
Sleep disturbances due to breathing
Wheezing
Excessive snoring
Coughing up blood
None
*
Gastrointestinal
Excessive appetite
Nausea
Gas
Indigestion
Diarrhea
Vomiting
Constipation
Difficulty swallowing
Vomiting blood
Yellowish skin color
Dark tarry stools
Abdominal pain
Change in bowel habits
Bloody stools
None
*
Genitourinary
Painful urination
Trouble starting urinary stream
Pelvic pain
Blood in urine
Inability to empty bladder
Genital sores
Urinary urgency
Inability to control bladder
Night time urination
Urinary frequency
Missed periods
Excessively heavy periods
None
*
Musculoskeletal
Muscle cramps
Joint pain
Stiffness
Muscle weakness
Joint swelling
Back pain
Muscle aches
None
*
Skin
Rash
Itching
Suspicious lesions
Changes in color of skin
Dryness
Poor wound healing
Changes in nail beds
None
*
Neurologic
Headaches
Falling down
Tingling
Poor balance
Fainting
Disturbances in coordination
Numbness
Memory loss
Difficulty with concentration
Tremors
Weakness
Sensation of room spinning
None
*
Psychiatric
Anxiety
Depression
None
*
Endocrine
Heat intolerance
Excessive thirst
Cold intolerance
Excessive hunger
Excessive urination
None
*
Heme / Lymphatic
Abnormal bruising
Bleeding
Skin discoloration
Enlarged lymph nodes
None
*
Allergic / Immunologic
Persistent infections
Seasonal allergies
HIV exposure
None
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Oklahoma City, OK 73189
Form Number 107
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