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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.
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
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31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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1931
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1929
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1927
1926
1925
1924
1923
1922
1921
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1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Review of Systems
* Required Information
If not listed here, please Discuss with your Physician
General
Chills
Feeling tired
Fever
Recent weight gain
Feeling poorly
Recent weight loss
None
Eyes
Eye pain
Discharge from eye(s)
Red eyes
Dry eyes
Eyesight problems
Eyes itch
None
ENT (Ear, Nose, and Throat)
Earache
Nasal discharge
Loss of hearing
Sore throat
Nosebleeds
Hoarseness
None
Cardiovascular
Heart rate is slow
Palpitations
Heart rate is fast
Lower extremity edema (swelling)
Chest pain
Leg claudication (cramping)
None
Respiratory
Shortness of breath (SOB)
Wheezing
SOB on exertion
Orthopnea (breathless while lying down)
Cough
Waking up coughing and short of breath
None
Gastrointestinal
Abdominal pain
Heartburn
Vomiting
Diarrhea
Constipation
Rectal bleeding
Nausea
Black or tarry stool
None
Genitourinary
Painful urination
Uncontrolled bladder
None
Muskuloskeletal
Joint pain
Joint stiffness
Muscle pain
Limb pain
Joint swelling
Limb swelling
None
Skin
Skin lesions
Change in a mole
Skin wound
Dry skin
Itching
An unusual growth
None
Neurological
Headache
Fainting
Convultions
Limb weakness
Dizziness
Difficulty walking
None
Psychiatric
Suicidal
Depression
Sleep disturbances
Change in personality
Anxiety
Emotional problems
None
Endocrine
Eye bulging
Erectile dysfunction
Hot flashes
Deepening of the voice
Muscle weakness
Feelings of weakness
None
Heme/Lymphatic
Swollen glands
Easy bleeding
Swollen glands in the neck
Easy bruising
None
Allergic/Immunologic
Hay fever
Hives
Asthma attacks
Contact allergy
Positive PPD
Food allergy
None
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