System Please check all that apply. – Negative Fatigue Sweats Change in appetite Weight Loss See comment General Fever Chills Bleeding problems Nutritional concerns Weight gain Comment Negative Headaches HX of head injury/concussion See comment Head Comment Negative Itching Glaucoma Corrective lenses/contacts Eyes Impaired vision Dryness Infection See comment Pain Redness Double vision Comment Negative Deafness Pain Dizziness Ears Impaired hearing Discharge Ringing in the ears See comment Comment Negative Dryness Obstruction See comment Nose and Sinuses Diminshed sense of smell Pain Sinusitis Bleeding Discharge Seasonal allergies Comment Negative Infection Blisters Difficulty swallowing Dental problems Sore throat Sore tongue Lip lesions Hoarseness See comment Mouth and Throat Pain Ulcers Canker sores Tonsilitis Comment Negative Limited motion Lumps See comment Neck Stiffness Pain Swollen glands Comment Negative Discharge Bleeding Retraction Tenderness Size See comment Breasts Comment Negative Itching Hair/changes Tumors Hives See comment Skin Rash Color change Infection Nails/changes Sores Lesion Comment Negative Asthma Exposure to tuberculosis Pneumonia Cyanosis (Bluish tint to skin, lips, nails) Respiratory Chest pain Sputum (color/frequency) Shortness of breath Wheezing Recurrent infection See comment Comment Negative Difficulty Breathing Varicose veins Chest pain Shortness of breath during exercise See comment Cardiovascular Murmur Fainting Palpitations Phlebitis Comment Negative Bleeding Swollen lymph nodes See comment Hematologic / Anemia Malignancy Transfusion Lymphatic Comment
System – Please check all that apply. General Negative Fever Fatigue Chills Sweats Bleeding problems Change in appetite Nutritional concerns Weight Loss Weight gain See comment Comment Head Negative Headaches HX of head injury/concussion See comment Comment Eyes Negative Impaired vision Pain Itching Dryness Redness Glaucoma Infection Double vision Corrective lenses/contacts See comment Comment Ears Negative Impaired hearing Deafness Discharge Pain Ringing in the ears Dizziness See comment Comment Nose and Sinuses Negative Diminshed sense of smell Bleeding Dryness Pain Discharge Obstruction Sinusitis Seasonal allergies See comment Comment Mouth and Throat Negative Sore throat Pain Infection Sore tongue Ulcers Blisters Lip lesions Canker sores Difficulty swallowing Hoarseness Tonsilitis Dental problems See comment Comment Neck Negative Stiffness Limited motion Pain Lumps Swollen glands See comment Comment Breasts Negative Discharge Bleeding Retraction Tenderness Size See comment Comment Skin Negative Rash Itching Color change Infection Hair/changes Nails/changes Tumors Sores Hives Lesion See comment Comment Respiratory Negative Chest pain Wheezing Asthma Pneumonia Sputum (color/frequency) Recurrent infection Exposure to tuberculosis Cyanosis (Bluish tint to skin, lips, nails) Shortness of breath See comment Comment Cardiovascular Negative Chest pain Murmur Palpitations Difficulty Breathing Shortness of breath during exercise Fainting Phlebitis Varicose veins See comment Comment Hematologic / Lymphatic Negative Anemia Bleeding Malignancy Swollen lymph nodes Transfusion See comment Comment