Do you use or have you ever used: 1. Alcohol # of glasses per week Beer Cocktails Wine 2. Cigarettes, presently Prior use # packs per day # of years 3. Illicit or recreational drugs (specify) IV. REVIEW OF SYSTEMS: General: Head, Eyes, Ears, Nose and Throat: Respiratory: Recent weight gain or loss Dizziness Chronic nasal congestion Shortness of breath Anorexia/Bulimia Ringing ears Asthma Bronchitis Lack of energy Headaches Pneumonia Loss of sense of smell Blurred Vision Bloody Hearing loss/deafness Other Tuberculosis None Other None None Endocrine/Hormonal: Breasts: Neurological Problems: Thyroid gland problems Discharge clear? bloody? milky? eakness/Loss of balance Lumps Reduction Numbness Memory loss Rapid weight gain or loss Excessive hunger/thirst Abnormal mammogram Headaches Temperature intolerance- Augmentation/Breast implants Migraine headaches hot flashes or feeling cold Seizures/Epilepsy Diabetes Hair loss Saline? Silicon? Pain Cancer Other None None Other None Gastrointestinal: Genito-Urinary: Skin/Extremities Nausea/Vomiting Ulcers Bladder infections Unexplained rash/inflammation Hepatitis Kidney infections Diarrhea Acne Blood in your stools Vaginal infections Skin Cancer Change in bowel habits Frequent urination Burn injury Colitis (ulcerative or Crohn's) changing in appearance Blood in the urine Constipation Excess hair growth Leaking urine Irritable Bowel Syndrome None Herpes Other Other Other None None Mental Health Problems: Depression Anxiety disorder None Schizophrenia
Do you use or have you ever used: 1. Alcohol # of glasses per week Beer Cocktails Wine 2. Cigarettes, presently Prior use # packs per day # of years 3. Illicit or recreational drugs (specify) IV. REVIEW OF SYSTEMS: General: Head, Eyes, Ears, Nose and Throat: Respiratory: Recent weight gain or loss Dizziness Chronic nasal congestion Shortness of breath Anorexia/Bulimia Lack of energy Headaches Blurred Vision Ringing ears Loss of sense of smell Asthma Bronchitis Pneumonia Bloody Other None Hearing loss/deafness None Tuberculosis Other None Endocrine/Hormonal: Breasts: Neurological Problems: Thyroid gland problems Discharge clear? bloody? milky? eakness/Loss of balance Rapid weight gain or loss Lumps Reduction Numbness Memory loss Excessive hunger/thirst Temperature intolerance- hot flashes or feeling cold Diabetes Hair loss None Gastrointestinal: Abnormal mammogram Augmentation/Breast implants Saline? Silicon? Pain Cancer Other None Genito-Urinary: Headaches Migraine headaches Seizures/Epilepsy Other None Skin/Extremities Nausea/Vomiting Ulcers Bladder infections Unexplained rash/inflammation Hepatitis Blood in your stools Change in bowel habits Diarrhea Kidney infections Vaginal infections Frequent urination Acne Skin Cancer Burn injury Colitis (ulcerative or Crohn's) Constipation Irritable Bowel Syndrome Other None Mental Health Problems: Blood in the urine Leaking urine Herpes Other None changing in appearance Excess hair growth None Other Depression Anxiety disorder None Schizophrenia