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Review of Systems
Please fill out the form below.
Patient Form E - Review of Systems
Today's Date
*
MM slash DD slash YYYY
Patient Name
*
Date of Birth
*
MM slash DD slash YYYY
No History
No History
General Questions
Change in appetite
Fatigue
Headache
Weight Gain
Weight Loss
Allergy Immunology
Seasonal Allergies
Sneezing
Ophthalmologic (Eye)
Blurred Vision
Eye Problems
Ent
Difficulty Swallowing
Ear Problems
Nose/Throat Problems
Snoring
Swollen Glands
Endocrine
Excessive Sweating
Excessive Thirst
Thyroid Problems
Respiratory
Breathing Problems
Cough
Shortness of Breath
Wheezing
Breast
Breast Lump
Breast Pain
Cardiovascular
Chest Pain
Edema
Irregular Heart Beat
Palpitations
Gastrointestinal
Abdominal Pain
Blood in Stool
Constipation
Diarrhea
Women Only
Irregular Menses
Painful Menses
Vaginal Discharge/Itching
Men Only
Difficulty Initiating Stream
Lump in Groin
Penile Discharge
Scrotal Pain
Scrotal Swelling
Genitourinary
Blood in Urine
Frequent Urination
Painful Urination
Musculoskeletal
Back Problems
Muscle Aches
Painful Joints
Weakness
Skin
Discoloration
Skin Lesions
Neurologic
Balance Difficulty
Dizziness
Memory Loss
Tremor
Psychiatric
Anxiety
Depressed Mood
Difficulty Sleeping
Suicidal Thoughts
Continue to Patient Form F - Preventive Health Medicine
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