Name: Date of Birth: / / Date: / / In to ensure that we have an accurate and current medical history for you, please complete this system review at each visit. Check all problems that apply to you. Please use the space at the bottom of the form to let our care staff know any changes in your health status since your last visit with us. Thank you. System Review (Please check all that apply) Endocrine: Diarrhea or dysentery (someone has reported you Eyes: Hormonal problems stop breathing during sleep) Genitourinary: Heart palpitations Wear glasses A.M. Headaches Bulging eyes Impaired vision Difficulty Sleeping Getting up more than Irritation of eyes once a night to urinate Integumentary: Lung Cancer Screening: Watering of eyes Trouble starting stream Sebaceous cysts age 55-77 years oId Trouble emptying bladder Respiratory: Skin cancer current smoker or quit Blood in urine Lumps in breasts in last 15 years Shortness of breath Gynecological: Number of you Breast cancer Wheezing smoked (Females Only) Raise phlegm Immune system: Average number of Menopause up blood smoked per day Multiple infections Hormonal replacement Daily cough Immune deficiency Birth control pills Cardiac: Seasonal allergies Neurological: pain Bad headaches Irregular heartbeat Blackout spells High blood pressure Convulsions Leg swelling Paralysis Numbness of hands Numbness of feet Changes in Health Status:
Name: Date of Birth: / / Date: / / In to ensure that we have an accurate and current medical history for you, please complete this system review at each visit. Check all problems that apply to you. Please use the space at the bottom of the form to let our care staff know any changes in your health status since your last visit with us. Thank you. System Review (Please check all that apply) Diarrhea or dysentery Endocrine: (someone has reported you Eyes: Hormonal problems stop breathing during sleep) Wear glasses Genitourinary: Heart palpitations A.M. Headaches Impaired vision Getting up more than Bulging eyes Difficulty Sleeping Irritation of eyes once a night to urinate Watering of eyes Trouble starting stream Integumentary: Lung Cancer Screening: Respiratory: Trouble emptying bladder Blood in urine Sebaceous cysts Skin cancer age 55-77 years oId current smoker or quit Shortness of breath Lumps in breasts in last 15 years Wheezing Gynecological: Breast cancer Number of you Raise phlegm (Females Only) smoked up blood Daily cough Menopause Hormonal replacement Immune system: Multiple infections Average number of smoked per day Birth control pills Immune deficiency Cardiac: Seasonal allergies pain Neurological: Irregular heartbeat Bad headaches High blood pressure Blackout spells Leg swelling Convulsions Paralysis Numbness of hands Numbness of feet Changes in Health Status: