Patient initials Checklist: Review of Systems Acct #: ______________________ (Acct # to be filled by staff) Date of Service: ______________ DOB: ___________________ Date of Injury: ___________________ Patient Name: __________________________________________________________________________________ General- Dry eyes or skin □ □Yellow Weight loss or gain Sore throat Urinary- □ □ Fatigue Frequency Hoarseness □ □ □ Fever or chills Urgency Thrush □ □ □ Weakness Burning or pain Non-healing sores □ □ □ Trouble sleeping Neck- Blood in urine □ □ Skin- Lumps Incontinence □ □ Rashes Swollen glands Change in urinary □ □ □ Lumps strength Pain □ □ Itching Vascular- Stiffness □ □ Dryness Calf pain with walking Breasts- □ □ Leg cramping Color changes Lumps □ □ □ Hair and nail changes Pain Musculoskeletal- □ □ Muscle or joint pain Head- Discharge □ □ Headache Stiffness Self-exams □ □ □ Head injury Back pain Breast-feeding □ □ □ Neck Pain Redness of joints Respiratory- □ □ Ears- Swelling of joints Cough □ □ Decreased hearing Trauma Sputum □ □ □ Ringing in ears Neurologic- Coughing up blood □ □ Earache Dizziness Shortness of breath □ □ □ Drainage Fainting Wheezing □ □ □
Patient initials Checklist: Review of Systems Acct #: ______________________ (Acct # to be filled by staff) Date of Service: ______________ DOB: ___________________ Date of Injury: ___________________ Patient Name: __________________________________________________________________________________ General- □ Weight loss or gain □ Dry □ Sore throat □Yellow eyes or skin Urinary- □ Fatigue □ Hoarseness □ Frequency □ Fever or chills □ Thrush □ Urgency □ Weakness □ Non-healing sores □ Burning or pain □ Trouble sleeping Neck- □ Blood in urine Skin- □ Lumps □ Incontinence □ Rashes □ Swollen glands □ Change in urinary □ Lumps □ Pain strength □ Itching □ Stiffness Vascular- □ Dryness Breasts- □ Calf pain with walking □ Color changes □ Lumps □ Leg cramping □ Hair and nail changes □ Pain Musculoskeletal- Head- □ Discharge □ Muscle or joint pain □ Headache □ Self-exams □ Stiffness □ Head injury □ Breast-feeding □ Back pain □ Neck Pain Respiratory- □ Redness of joints Ears- □ Cough □ Swelling of joints □ Decreased hearing □ Sputum □ Trauma □ Ringing in ears □ Coughing up blood Neurologic- □ Earache □ Shortness of breath □ Dizziness □ Drainage □ Wheezing □ Fainting
NEW_PATIENT_PAPERWORK_Michigan_August_updated.docx