HEALTHWISE MEDICAL ASSOCIATES, LLP
REVIEW OF SYSTEMS
PATIENT PRINTED NAME:
DATE OF COMPLETION OF FORM:
PATIENT DATE OF BIRTH:
PLEASE LIST YOUR MEDICATION, STRENGTH AND HOW MANY TIMES A DAY YOU TAKE
THE MEDICATION:
Medication/Vitamin Supplements
Strength
Times Per Day
CIRCLE All That Apply: WITHIN THE PAST YEAR HAVE YOU HAD
General:
Unexplained Weight Loss, Weight Gain, Fevers, Chills, Appetite Changes, Hot or Cold
Intolerance, fatigue, Weakness, Insomnia, Excessive Thirst: Comments
Allergies:
Allergic Reactions: Comments
ARE YOU ALLERGIC TO ANY MEDICATIONS? NO YES: LIST
Skin:
New or Changing Moles, Rashes, Color Changes, Itching, Dryness, Bruising, Non-Healing
Sores: Comments
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Review of Systems
Hematological:
Anemia, Bruising, Swelling: Comments
Neurological:
Headaches, Dizzy Spells, Tremors, Seizures, Numbness, Tingling, Memory
Problems, Trouble Walking, Speech Problems, Balance Problems, Trouble
Concentrating: Comments
Musculoskeletal:
Neck Pain, Back Pain, Joint Pain, Joint Swelling, Muscle Pain, Cramping,
Broken Bones: Comments
Eyes:
Blurred Vision, Double vision, Pain, Itching, Redness, Glasses: Comments
Ears:
Hearing Loss, Ringing, Pain, Itching, Hearing Aid: Comments
Nose:
Bleeding, Running, Pain, Sense of Smell Change: Comments
Mouth:
Dental/Gum Problems, Sores, Sense of Taste Change: Comments
Sinus:
Pain, Pressure, Congestion, Snoring: Comments
Throat:
Pain, Hoarseness, Difficulty Swallowing, Swollen Glands, Voice Change: Comments
Heart:
Chest Pain or Pressure, Palpitations, Racing Heart, Irregular Pulse, Fainting, Cold Sweats:
Comments
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Review of Systems
Lungs:
Difficulty Breath, Shortness of Breath, Coughing, Wheezing, Phlegm: Comments
Gastrointestinal:
Abdominal Pain, Nausea, Vomiting, Spitting Up Blood, Diarrhea, Constipation,
Black Stools, Bloody Stools, Heartburn, Hemorrhoids: Comments
Urinary:
Excessive Urination, Leaking, burning, Blood in Urine, Painful Urination,
Difficulty, Urgency, Waking up at night to Urinate: Comments:
Extremities:
Arm/Leg Swelling, Cold Extremities, Cramping: Comments:
Female:
Painful Periods, Irregular Periods, heavy Periods, Bleeding Between Periods,
Discharge, Sores, Sexually Transmitted Disease, Infertility, Pregnancy, menopause,
Hot Flashes, Painful Intercourse, Bleeding Following Intercourse, Abnormal Pap,
Decreased Sexual Desire, Form of Birth Control
Last Menstrual Period
#of Pregnancies
# of Births
Comments:
Male:
Discharge, Sores, Infertility, hernias, Testicular Lumps, Swelling, Pain, Sexually
Transmitted Disease, Difficulty Ejaculating, Difficulty with Erection, Difficulty
Maintaining Erection, Decreased Sexual Desire: Comments
Psychological:
Depression, nervousness, Hallucinations, Emotional Instability: Comments
Past Surgical History:
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Review of Systems
Past Medical History:
Social History: NO YES Cigarettes – Packs per day
# of years
Caffeine: NO YES Cups per day
Alcohol: NO YES Drinks per day
Drinks per week
History of Alcohol Abuse: No Yes – Quit Date:
Living Arrangements:
Married
Single
Cultural and Linguistic Needs:
Languages Spoken in the Home:
Interpreter Needed: YES NO
Refusal of Blood Products: YES NO
Living Will:
YES
NO
Alternative Healing Regimes:
Family History: Cancer - Mother Father Sister Brother Comments:
Stroke, Kidney Disease, Liver Disease, Alzheimer’s, Blood Disorders, Other:
PLEASE LIST NAMES OF OTHER HEALTHCARE PROVIDERS WHOSE CARE YOU ARE
UNDER:
EMERGENCY CONTACT INFORMATION:
Name
Phone
Relationship