Negative Diarrhea Hernia Abdominal pain Bloating Nausea Heartburn Constipation Belching Hemorrhoids Gastrointestinal Vomiting Food intolerance Laxative or enema use Black stools See comment Vomiting Change in bowel Ulcers Stooling “accidents” blood habits Comment Negative Hesitancy Urgency Incontinence Bedwetting Frequency See Genitourinary Burning Infection Blood in urine Kidney stones Leakage Toilet trained comment Comment Negative Started menstrual cycle Sexually transmitted disease See comment Discharge Painful menstrual cramps Childbirth Reproductive Itching Contraceptive use Abortion Infection Complication of pregnancy Painful intercourse Comment Negative Pain Atrophy Joint pain Back Injury See comment Musculoskeletal Muscle cramps Weakness Swelling Fractures Curvature of spine Comment Negative Hair/changes Urinary frequency Endocrine / Heat or cold intolerance Excessive sweating See comment Metabolic Diabetes Thirst Comment Negative Double vision Tic Hyperactivity Headaches Vision loss or change Tingling Developmental delay Fainting Paralysis Burning Unusual development/behavior Neurologic Seizures Pain Poor coordination or balance Short attention span Dizziness Numbness Learning problems See comment Blindness Attention problems Comment Negative Does not play with others or has few friends Sleep disturbances Fights with other children Unhappy, down or hopeless Defiant or argumentative with adults Psychiatric / Suicidal expression or self-injurious behavior Suspected drug or alcohol use Severe mood swings Strange or nonsensical thinking or behavior Emotional Excessive worries or fears Recent changes in family or school Fidgety, unable to sit still or trouble concentrating See comment Comment
Gastrointestinal Negative Nausea Vomiting Vomiting blood Diarrhea Heartburn Food intolerance Change in bowel habits Hernia Constipation Laxative or enema use Ulcers Abdominal pain Belching Black stools Stooling “accidents” Bloating Hemorrhoids See comment Comment Genitourinary Negative Burning Hesitancy Infection Urgency Blood in urine Incontinence Kidney stones Bedwetting Leakage Frequency Toilet trained See comment Comment Reproductive Negative Discharge Itching Infection Started menstrual cycle Painful menstrual cramps Contraceptive use Complication of pregnancy Sexually transmitted disease Childbirth Abortion Painful intercourse See comment Comment Musculoskeletal Negative Muscle cramps Pain Weakness Atrophy Swelling Joint pain Fractures Back Injury Curvature of spine See comment Comment Endocrine / Metabolic Negative Heat or cold intolerance Diabetes Hair/changes Excessive sweating Thirst Urinary frequency See comment Comment Neurologic Negative Headaches Fainting Seizures Dizziness Blindness Double vision Vision loss or change Paralysis Pain Numbness Tic Tingling Burning Poor coordination or balance Learning problems Attention problems Hyperactivity Developmental delay Unusual development/behavior Short attention span See comment Comment Psychiatric / Emotional Negative Sleep disturbances Unhappy, down or hopeless Suicidal expression or self-injurious behavior Severe mood swings Excessive worries or fears Fidgety, unable to sit still or trouble concentrating Does not play with others or has few friends Fights with other children Defiant or argumentative with adults Suspected drug or alcohol use Strange or nonsensical thinking or behavior Recent changes in family or school See comment Comment
GYNSystemForm(1).docx