Review of Symptoms: (Please check any current symptom(s) you have) General: Shortness of Breath  Neurological: Weight loss  Skin: Numbness/Tingling How much  Rashes or Itching Arm or Leg Weakness _________________________   Over what time  Change in Skin Color or Moles  Light-Headed/Dizzy/Fainting period____________ Varicose Veins Tremors/Headaches    Fevers Skin Cancer  Max  Psychiatric: Temp________________________ Gastrointestinal: Anxiety/Agitation Chills   Difficult or Painful Swallowing Depression sweats    Abdominal Pain Crying for No Reason    Fatigue  Nausea  Insomnia Eyes: Vomiting Alcoholism   Wear Glasses/Contact Lenses Heartburn Drug Problem    Blurred Vision Lump or Sensation in Throat   Hematologic:  Double Vision  Food Sticking Glare Easy Bruising Diarrhea  Redness Gum or Nose Bleeding Constipation   Blood Transfusions  Itching Rectal Bleeding   Irritation  Black, Tarry or Bloody Stool Endocrine: Dryness  Appetite Poor  Heat or Cold Intolerance Jaundice  Ears, Nose, Throat: Excessive Skin Dryness  Excessive Thirst  Hard of Hearing or Deaf Genitourinary:  Excessive Urination Ringing in Ears    Kidney Stones Enlarged Lymph nodes  Weight Problem  Pelvic Pain  Chronic Sinus Problems Hot Flashes  Incontinence    Sore Throat Burning or Pain on Urination  Mouth Pain/Sores  Blood in Urine  Difficult Urination  Allergies/Immunology: Changes/Difficulty In: Men: Prostate Problems   History of Allergies Taste  Dialysis Infections Chronic  Smell Musculoskeletal: Cardiovascular: Joint Pain/Arthritis  Pain/Angina Pectoris  Muscle or Joint Weakness  Palpitations/Heart Murmur   Back Pain  Irregular Heart Beat Pain Bone Pace maker/defibrillator  Muscle Aches  Respiratory: or Frequent Cough Chronic Bloody Sputum  Patient Name: _________________________________________________________________ DOB: ________________________
Review of Symptoms: (Please check any current symptom(s) you have) General:  Weight loss How much _________________________ Over what time period____________  Fevers  Max Temp________________________  Chills  sweats  Fatigue Eyes:  Wear Glasses/Contact Lenses  Blurred Vision  Double Vision Glare Redness  Itching Irritation  Dryness Ears, Nose, Throat:  Hard of Hearing or Deaf  Ringing in Ears  Enlarged Lymph nodes  Chronic Sinus Problems  Sore Throat  Mouth Pain/Sores Changes/Difficulty In: Taste  Smell Cardiovascular:  Pain/Angina Pectoris  Palpitations/Heart Murmur  Irregular Heart Beat  Pace maker/defibrillator Respiratory: Chronic or Frequent Cough  Bloody Sputum  Shortness of Breath Skin:  Rashes or Itching  Change in Skin Color or Moles  Varicose Veins  Skin Cancer Gastrointestinal:  Difficult or Painful Swallowing  Abdominal Pain  Nausea  Vomiting  Heartburn  Lump or Sensation in Throat  Food Sticking  Diarrhea  Constipation  Rectal Bleeding  Black, Tarry or Bloody Stool Poor Appetite  Jaundice Genitourinary:  Kidney Stones  Pelvic Pain  Incontinence  Burning or Pain on Urination  Blood in Urine  Difficult Urination  Men: Prostate Problems  Dialysis Musculoskeletal:  Joint Pain/Arthritis  Muscle or Joint Weakness  Back Pain Bone Pain  Muscle Aches Neurological:  Numbness/Tingling  Arm or Leg Weakness  Light-Headed/Dizzy/Fainting  Tremors/Headaches Psychiatric:  Anxiety/Agitation  Depression  Crying for No Reason  Insomnia  Alcoholism  Drug Problem Hematologic: Easy Bruising  Gum or Nose Bleeding  Blood Transfusions Endocrine:  Heat or Cold Intolerance  Excessive Skin Dryness  Excessive Thirst  Excessive Urination  Weight Problem  Hot Flashes Allergies/Immunology:  History of Allergies Chronic Infections Patient Name: _________________________________________________________________ DOB: ________________________
New-Patient-Form-1-1.docx