Review Of Systems
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
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 (Full Legal Name)
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
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
Please select only the symptoms you CURRENTLY are experiencing.
Select all that apply - if no symptoms, please select 'NONE'
General
chills
weight loss
night sweats
fever
weight gain
appetite loss
fatigue
NONE
Eyes
double vision
blurring
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
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
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
blood in urine
urinary urgency
inability to control bladder
urinary frequency
night time urination
NONE
Genitourinary
painful urination
pelvic pain
blood in urine
inability to empty bladder
urinary urgency
inability to control bladder
missed periods
urinary frequency
night time urination
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
changes in nail beds
NONE
Neurologic
headaches
tingling
fainting
disturbances in coordination
numbness
memory loss
tremors
weakness
sensation of room spinning
NONE
Psychiatric
anxiety
depression
NONE
Endocrine
heat intolerance
excessive thirst
cold intolerance
excessive urination
NONE
Heme/Lymphatic
abnormal bruising
bleeding
enlarged lymph nodes
NONE
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 576
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.