Patient Name: ____________________________________________ Date of Birth: __________________ Review of Systems – Please Circle any Symptoms that CURRENTLY Apply to you (past/present) Constitution Eyes Endocrine Allergy/Immunology Activity Change Eye Discharge Cold Intolerance Environmental Allergies Appetite Change Eye Itching Heat Intolerance Food Allergies Chills Eye Pain Very Thirsty Impaired Immune System Sweating Eye Redness Excessive Hunger Fatigue Light Sensitivity Urinate Large Volumes Fever Visual Disturbance Unexpected Weight Change HENT Respiratory GU Neurological Facial Swelling Apnea Difficulty Urinating Dizziness Neck Swelling Chest Tightness Painful Intercourse Facial Asymmetry Neck Stiffness Choking Painful Urination Headaches Ear Discharge Cough Bedwetting Light-Headedness Hearing Loss Shortness of Breath Flank Pain Numbness Ear Pain Vibration of Chest Frequent Urination Seizures Ringing in Ears Wheezing Genital Sore Speech Difficulty Nosebleeds Blood in Urine Loss of Consciousness Congestion Cardiovascular Menstrual Problems Tremors Runny Nose Chest Pain Penile Discharge Weakness Postnasal Drip Leg Swelling Penile Pain Sneezing Palpitations Penile Swelling Hematologic Sinus Pressure Pelvic Pain Enlarged Lymph Nodes Dental Problem GI Scrotal Swelling Bruises/Bleeds Easily Drooling Swelling of Abdomen Testicular Pain Mouth Sores Abdomen Pain Urgent Urination Psychiatric Sore Throat Anal Bleeding Urine Decreased Agitation Trouble Swallowing Blood in Stool Vaginal Bleeding Behavior Problems Constipation Vaginal Discharge Confusion Skin Diarrhea Vaginal Pain Decreased Concentration Color Change Nausea Depression Pale Rectal Pain Musculoskeletal Hallucinations Rash Vomiting Joint Pain Hyperactive Wound Back Pain Nervous/Anxious Problems Walking Self-Injury Joint Swelling Sleep Disturbance Muscle Pain Suicidal Ideas List ALL Providers/Specialist seen: WHO WHEN WHERE _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________
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Patient Name: ____________________________________________ Date of Birth: __________________
Review of Systems – Please Circle any Symptoms that CURRENTLY Apply to you (past/present)