Richard J. Finder, M.D., F.A.C.S.  Jonathan L. Masel, M.D., F.A.C.S.  (954) 961-7500
Patient:_______________________
Date:________________
Review of Systems
Do you now or have you had any problems related to the following systems? Circle Yes or No.
Constitutional Symptoms
Fever
Y
N
Chills
Y
N
Headache
Y
N
Other __________________________________________
Integumentary
Skin rash
Y
N
Boils
Y
N
Persistent itch
Y
N
Other __________________________________________
Eyes
Blurred vision
Y
N
Double vision
Y
N
Pain
Y
N
Other __________________________________________
Musculoskeletal
Joint pain
Y
N
Neck pain
Y
N
Back pain
Y
N
Other __________________________________________
Allergic/Immunologic
Hay Fever
Drug allergies
Other __________________________________________
Ear/Nose/Throat/Mouth
Ear infection
Y
N
Sore throat
Y
N
Sinus problem
Y
N
Other __________________________________________
Neurological
Tremors
Y
N
Dizzy spells
Y
N
Numbness/tingling
Y
N
Other __________________________________________
Genitourinary
Urine retention
Y
N
Painful urination
Y
N
Urinary frequency
Y
N
Other __________________________________________
Endocrine
Excessive thirst
Y
N
Too hot/cold
Y
N
Tired/sluggish
Y
N
Other __________________________________________
Respiratory
Wheezing
Y
N
Frequent cough
Y
N
Shortness of breath
Y
N
Other __________________________________________
Gastrointestinal
Abdominal pain
Y
N
Nausea/vomiting
Y
N
Indigestion/heartburn
Y
N
Other __________________________________________
Hematologic/Lymphatic
Swollen glands
Blood clotting problem
Cardiovascular
Chest pain
Varicose veins
High blood pressure
Psychologic
Are you unhappy with your life?
Do you feel severely depressed?
Have you considered suicide?
Y
Y
Y
Y
Y
N
N
N
N
N
Other __________________________________________
N
N
Other __________________________________________
Y
Y
Y
N
N
N
Other __________________________________________
Physician use only: (Comments/Notes)
Answers
0-1
2-9
10+
Y
Y
Level of Service
1 or 2
3
4 or 5
Physician Signature: _______________________________________________