Review of Systems Checklist: (please check all that apply to your current condition) General- Head- Eyes- Weight loss or gain Headache Vision loss/changes □ □ □ Fatigue Head injury Glasses or Cataracts □ □ □ Fever or chills Neck pain Pain □ □ □ Weakness Redness □ □ Trouble sleeping Flashing lights □ □ Hair and nail changes Cataracts □ □ Glaucoma □ Nose- Throat- Neck- Stuffiness Bleeding Lumps □ □ □ Discharge Dentures Swollen Glands □ □ □ Itching Sore Tongue Pain □ □ □ Hay Fever Dry Mouth Stiffness □ □ □ Nosebleeds Sore Throat □ □ Pain Hoarseness □ □ Thrush □ Non-healing Sores □ Breasts- Cardiovascular- Lumps Chest Pain/Discomfort Tightness □ □ □ Pain Palpitations Swelling □ □ □ Discharge Shortness of breath with activity □ □ Self-Exam Difficulty breathing lying down □ □ Breast-feeding Sudden awakening from with shortness of breath □ □ Respiratory- Urinary- Gastrointestinal- Cough Frequency Swallowing difficulties □ □ □ Sputum Urgency Heartburn □ □ □ Coughing up blood Burning or pain Change in appetite □ □ □ Shortness of breath Trauma Nausea □ □ □ Wheezing Blood in urine Change in bowel habits □ □ □ Painful breathing Incontinence Rectal bleeding □ □ □ Change in urinary Constipation □ □ Strength Diarrhea □ Yellow skin or eyes □ Vascular- Musculoskeletal Neurologic- Calf pain with walking Muscle or joint pain Dizziness □ □ □ Leg cramping Stiffness Fainting □ □ □ Back pain Seizures □ □ Hematologic- Redness of joints Weakness □ □ Ease of bruising Swelling of joints Numbness □ □ □ Ease of bleeding Tingling □ □ Tremor □ Endocrine- Psychiatric- Heat or cold intolerance Nervousness □ □ Sweating PTSD □ □ Frequent Urination Depression □ □ Thirst □ Page 3 of 5 Social History: Are you currently employed ? □Yes □No
Review of Systems Checklist: (please check all that apply to your current condition) General- Head- Eyes- □ Weight loss or gain □ Headache □ Vision loss/changes □ Fatigue □ Head injury □ Glasses or Cataracts □ Fever or chills □ Neck pain □ Pain □ Weakness □ Redness □ Trouble sleeping □ Flashing lights □ Hair and nail changes □ Cataracts □ Glaucoma Nose- Throat- Neck- □ Stuffiness □ Bleeding □ Lumps □ Discharge □ Dentures □ Swollen Glands □ Itching □ Sore Tongue □ Pain □ Hay Fever □ Dry Mouth □ Stiffness □ Nosebleeds □ Sore Throat □ Pain □ Hoarseness □ Thrush □ Non-healing Sores Breasts- Cardiovascular- □ Lumps □ Chest Pain/Discomfort □ Tightness □ Pain □ Palpitations □ Swelling □ Discharge □ Shortness of breath with activity □ Self-Exam □ Difficulty breathing lying down □ Breast-feeding □ Sudden awakening from with shortness of breath Respiratory- Urinary- Gastrointestinal- □ Cough □ Frequency □ Swallowing difficulties □ Sputum □ Urgency □ Heartburn □ Coughing up blood □ Burning or pain □ Change in appetite □ Shortness of breath □ Trauma □ Nausea □ Wheezing □ Blood in urine □ Change in bowel habits □ Painful breathing □ Incontinence □ Rectal bleeding □ Change in urinary □ Constipation Strength □ Diarrhea □ Yellow skin or eyes Vascular- Musculoskeletal Neurologic- □ Calf pain with walking □ Muscle or joint pain □ Dizziness □ Leg cramping □ Stiffness □ Fainting □ Back pain □ Seizures Hematologic- □ Redness of joints □ Weakness □ Ease of bruising □ Swelling of joints □ Numbness □ Ease of bleeding □ Tingling □ Tremor Endocrine- Psychiatric- □ Heat or cold intolerance □ Nervousness □ Sweating □ PTSD □ Frequent Urination □ Depression □ Thirst Page 3 of 5 Social History: Are you currently employed ? □Yes □No
patient_intakeform-2018.docx