REVIEW OF SYSTEMS Sample Clauses

REVIEW OF SYSTEMS. SYMPTOM REVIEW Gastrointestinal  poor appetite  abdominal pain  indigestion  trouble swallowing  diarrhea  constipation  change in bowel habits  nausea or vomiting  rectal bleeding or blood in stools  history of liver disease or abnormal liver tests Cardiovascular  chest pain  history of angina or heart attack  history of high blood pressure  history of irregular beat  history of poor circulation Pulmonary/lungs  shortness of breath  persistent cough  coughing up blood  asthma or wheezing Muscle/joint/bone  swelling of ankles or legs pain, weakness or numbness in  arms or hands  back or hips  legs or feet  neck or shoulders Neurologic  history of stroke  blackouts or loss of consciousness General  weight gain/loss of 10+ lbs during last 6 months  poor sleep  fever  headache  depression Eyes, ears, nose, throat  blurred vision  other change in vision  history of glaucoma or cataracts  loss of hearing  ringing in ears  sinus problems  hoarseness Genitourinary  frequent or painful urination  blood in urine Skin  itching  easy bruising  change in moles Endocrine  history of diabetes  history of thyroid disease  change in tolerance to hot or cold weather  excessive thirst Women only  abnormal Pap smear  bleeding between periods date of last mammogram Men only  Elevated PSA Anything else?  Are you experiencing an unusually stressful situation?  Are there any specific personal issues you would like to bring up at the time of your visit? *************************************************** Thank you for taking the time to complete this form.

REVIEW OF SYSTEMS. Please circle the symptoms that are prevent at this time General Fever Weight gain Weight loss Chills Fatigue Sweats Loss of appetite Anorexia Malaise Headaches Eyes Vision loss Light sensitivity Double vision Blurring Eye pain Diplopia Irritation Discharge Photophobia Ears, Nose and Throat Ringing in ears Decreased hearing Congestion Hoarseness Earache Difficulty swallowing Ear discharge Nose bleeds Sore Throat Runny Nose Cardiovascular Difficulty breathing lying down Leg cramps during exertion Ankle swelling Palpitations Fainting spells Chest pain Heme/Lymphatic Tendency towards bleeding Abnormal bruising Enlarged lymph glands Respiratory Shortness of breath at rest Sputum Production Shortness of breath with exertion Cough Chest pain Snoring Coughing up blood Wheezing Waking up gasping for breath Gastrointestinal Bloody or black stools Abdominal pain Nausea Constipation Vomiting Diarrhea Change in bowel habits Genitourinary Frequent urination at night Difficulty starting urination Blood in urine Loss of bladder control Urinary urgency/frequency Vaginal discharge Incontinence Abnormal menstrual period Pelvic pain Musculoskeletal Muscle weakness Bone pain in last 3 months Joint pain in last 3 months Muscle cramps Joint pain Back pain Joint swelling Joint stiffness Stiffness Allergic/Immunologic Persistent infections HIV exposures Hives Hay fever Skin Poor skin healing Hair loss Itching Rash Dryness Suspicious lesions Jaundice Neurological Memory loss Tingling sensation Tremors Balance problems Transient paralysis Weakness Unsteadiness Speech problems Numbness Headaches Seizures Psychiatric Suicidal thoughts Hallucinations Anxiety Depression Memory loss Mental disturbance Paranoia