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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
---------- Date of Birth ----------
First Name
Last Name
Month
Day
Year
Gender
January
February
March
April
May
June
July
August
September
October
November
December
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
2024
2023
2022
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
Male
Female
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
Please mark only the symptoms you are CURRENTLY experiencing.
Mark all that apply. If no symptoms, please mark "NONE."
Would you say that your health is:
good
fair
poor
GENERAL
sweats
chronic fatigue
recent weight loss
chills
trouble sleeping
recent weight gain
fever
NONE
SKIN
acne
psoriasis
rashes
scars
NONE
EYES
glaucoma
blurred vision
cataracts
glasses
contacts
NONE
EARS, NOSE AND THROAT
dizziness
neck lumps / masses
ringing in ears
caps (teeth)
loose teeth
dentures or partial plates
sore throat or sinus infection (recent)
NONE
ENDOCRINE / METABOLIC
urination difficulties
gout
excessive thirst
hair growth
NONE
ALLERGIES
metal allergy
hay fever
hives
NONE
HEART / VASCULAR
dropsy (retaining fluids)
chest pain
dyspnea (shortness of breath)
palpitations
stroke
racing heartbeat
irregular heartbeat
ankle swelling / edema
hardening of the arteries
NONE
RESPIRATORY
cold (recent)
cough
coughing up blood
bronchitis
wheezing
NONE
GASTROINTESTINAL
tarry (black) stools
hemorrhoids
antacid use
food allergies / intolerance
vomiting / nausea
jaundice
heartburn
recent gastrointestinal bleeding
change in bowel habits
pain before or after meals
laxative use / constipation
diarrhea
NONE
KIDNEY / BLADDER
pain / burning with urination
kidney / bladder infections
incontinence
strictures / obstruction
frequent urination
bladder trouble
urinating at night
NONE
----------------------------------------------------------------------------------------------
How many times per night?
1
2
3
4
>4
GYNECOLOGICAL
Could you be pregnant now?
yes
no
BONE MARROW
benzene or other chemical exposure
bleeding / bruising tendencies
anemia
radiation
NONE
NEUROMUSCULAR
headaches
convulsions
severe / recurrent sprains
paralysis
neck pain or injury
pain or cramps when walking
numbness
torn ligaments
black outs
sciatica
dizziness
back pain
visual disturbances
forgetfulness
trick knees
stroke
gout
NONE
PSYCHIATRIC
severe anxiety
suicidal
nervous breakdown
depression
NONE
OTHER SYMPTOMS
Please list additional symptoms:
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