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Review Of Systems
Please select the name of the doctor you are scheduled to see.
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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
Review of Systems
* Required Information
Please mark only the symptoms you are
currently
experiencing.
Mark all that apply. If no symptoms, please mark "
None
".
General
Weight loss
Fever
Fatigue
Weight gain
Persistent infections
None
Eyes
Visual disturbances
Glasses/Contacts
None
Ear, Nose, and Throat
Hearing loss
Sinus pain
Seasonal allergies
Oral ulcers
None
Cardiovascular
Chest pain
Swelling hands/feet
Difficulty breathing on exertions
Palpitations
Shortness of breath
None
Respiratory
Chronic cough
Wheezing
Difficulty breathing
Coughing blood
None
Breast
Mass/lump
Breast pain
Nipple discharge
None
Gastrointestinal
Constipation
Bloody stool
Nausea
Chronic diarrhea
Hemorrhoids
Vomiting
Abdominal pain
Excessive gas
Change in bowel habits
Jaundice
Heartburn
Pain with swallowing
Fecal incontinence
Difficulty swallowing
None
Genitourinary
blood in urine
pelvic pain
vaginal dryness
painful urination
urinary frequency
vaginal discharge
painful menstruation
urinary urgency
vaginal itch or burning
menstrual irregularities
excessive urination at night
painful intercourse
urine leakage
urine leakage
urinary frequency
testicular mass
painful urination
urinary urgency
testicular pain
change in urinary stream
impotence
penile lesions
excessive urination at night
urethral discharge
blood in urine
NONE
Musculoskeletal
joint pain
muscle pain
muscle weakness
NONE
Skin
dry skin
rash
new sore/lesion
change in wart or mole
hives
skin ulcer
NONE
Neurologic
fainting
numbness
seizures
decreased memory
trouble walking
headaches
NONE
Psychiatric
anxiety
frequent crying
change in sleep pattern
depression
fearful
NONE
Endocrine
cold intolerance
hair changes
heat intolerance
hot flashes
NONE
Heme/Lymphatic
easy bruising
excessive bleeding
gland problems
NONE
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