(Please specify below) Please provide details for all checked REVIEW OF SYSTEMS: Please check (√) any current problems you have on the list below. Constitutional Respiratory Skin Fevers/chills/sweats / Eczema or Rash Unexplained weight loss/gain Difficulty breathing Chemical Or Jewelry Rash / Fatigue/weakness Sensitivity Gastrointestinal Excessive thirst or urination Abnormal bleeding or bruising Abdominal pain Eyes Blood in bowel movement Change in vision (blurry Neurological Nausea/vomiting/diarrhea vision or decreased vision or Headaches other changes) Reflux or gastritis Dizziness/light-headedness Ears/Nose/Throat/Mouth ulcer Numbness in hands, feet, Difficult hearing/ringing in Genitourinary fingers or other areas (specify ears Nighttime urination please) Problems with teeth/gums Leaking urine Memory loss Hay fever/allergies Unusual vaginal bleeding Loss of coordination Difficulty tasting or ‘funny Discharge: or vagina Difficulty walking taste’ with food or drinks Sexual function problems Tremors or shaking Psychiatric Cardiovascular Sexually transmitted disease Anxiety/stress pain/discomfort Difficulty with orgasm Hallucinations Leg pain with exercise Difficulty with erection Depression Palpitations or irregular Musculoskeletal beat Muscle/joint pain Other condition “nervous” Chest (breast) Blood/Lymphatic Joint swelling or inflammation Breast lump/discharge Unexplained lumps Arthritis Easy bruising/bleeding Rheumatoid arthritis Other (please specify)_______ _________________________ Please provide details for all checked boxes: _______ 3 OCCUPATIONAL HISTORY Work History: Jobs Start with Most Recent – Any Exposure to Vapors Gas Dusts or Date (from / to ) Company / Type of Industry Job Title Fumes (specify)
(Please specify below) Please provide details for all checked REVIEW OF SYSTEMS: Please check (√) any current problems you have on the list below. Constitutional Fevers/chills/sweats Unexplained weight loss/gain Fatigue/weakness Excessive thirst or urination Eyes Change in vision (blurry vision or decreased vision or other changes) Ears/Nose/Throat/Mouth Difficult hearing/ringing in ears Problems with teeth/gums Hay fever/allergies Difficulty tasting or ‘funny taste’ with food or drinks Cardiovascular pain/discomfort Leg pain with exercise Palpitations or irregular beat Chest (breast) Breast lump/discharge Respiratory Difficulty breathing Gastrointestinal Abdominal pain Blood in bowel movement Nausea/vomiting/diarrhea Reflux or gastritis ulcer Genitourinary Nighttime urination Leaking urine Unusual vaginal bleeding Discharge: or vagina Sexual function problems Sexually transmitted disease Difficulty with orgasm Difficulty with erection Musculoskeletal Muscle/joint pain Joint swelling or inflammation Arthritis Rheumatoid arthritis Skin / Eczema or Rash Chemical Or Jewelry Rash / Sensitivity Abnormal bleeding or bruising Neurological Headaches Dizziness/light-headedness Numbness in hands, feet, fingers or other areas (specify please) Memory loss Loss of coordination Difficulty walking Tremors or shaking Psychiatric Anxiety/stress Hallucinations Depression Other “nervous” condition Blood/Lymphatic Unexplained lumps Easy bruising/bleeding Other (please specify)_______ _________________________ Please provide details for all checked boxes: _______ 3 OCCUPATIONAL HISTORY Work History: Jobs – Start with Most Recent Date (from / to ) Company / Type of Industry Job Title Any Exposure to Vapors Gas Dusts or Fumes (specify)