Review Of Systems
Please select the name of the doctor you are scheduled to see.
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Patient Information
*
Please provide the patient's full legal name as it appears on their 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
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5
6
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31
Birth Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
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1993
1992
1991
1990
1989
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1972
1971
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1963
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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 select only the symptoms you are CURRENTLY experiencing.
Select all that apply. If no symptoms, please Select "None."
*
General
Fever
Weight gain
Tiredness
Fatigue
Persistent infections
Night sweats
Weight loss
Chills
None
*
Eyes
Headache
Blurred vision
Eye pain
Double vision
Excessive tearing
Glasses/contacts
None
*
Ear, Nose, & Throat
Sinus pain
Hearing loss
Ear discharge
Sleep apnea
Seasonal allergies
Oral ulcers
None
*
Cardiovascular
Chest pain
Shortness of breath
Swelling hands/feet
Calf pain
Palpitations
Elevated blood pressure
None
*
Respiratory
Cough
Difficulty breathing
Chronic cough
Wheezing
Bloody sputum
Difficulty breathing on exertion
None
*
Breast
Breast mass
Breast pain
Nipple discharge
None
*
Gastrointestinal
Constipation
Hemorrhoids
Nausea
Chronic diarrhea
Excessive gas
Vomiting
Abdominal pain
Indigestion
Change in bowel habits
Bloody stool
Heartburn
None
*
Genitourinary
Urinary frequency
Vaginal itch or burning
Incontinence
Urinary urgency
Painful urination
Pelvic pain
Urination at night
Absence of menstruation
Blood in urine
Change in bladder habits
Menstrual irregularities
Stress incontinence
None
*
Genitourinary
Painful urination
Urinary urgency
Testicular pain
Change in bladder habits
Impotence
Blood in urine
Urination at night
Discharge
Difficulty with erection
Urinary frequency
Testicular mass
Incontinence
None
*
Musculoskeletal
Joint stiffness
Joint redness
Joint swelling
Muscle pain
Joint pain
Decreased range of motion
Muscle weakness
None
*
Skin
Dryness
Rash
New sore/lesion
Bruising
Hives
Skin ulcer
None
*
Neurologic
Fainting
Numbness
Trouble walking
Decreased memory
Incontinence stool
Seizures
Weakness of extremities
Incontinence urine
Headaches
None
*
Psychiatric
Anxiety
Panic attack
Fearful
Change in sleep pattern
Depression
Hallucinations
None
*
Endocrine
Cold intolerance
Hair changes
Heat intolerance
Thyroid problems
Excessive urination
Excessive thirst
Sexual dysfunction
None
*
Heme/Lymphatic
Anemia
Abnormal bleeding
Blood clots
Easy bruising
Excessive bleeding
Prolonged bleeding
None
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 112
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