HOWARD NIZAR, M.D., FACP Periodic Examination and Review of Systems The purpose of this form is to serve as an update to information already present in your medical record. It is important for you to fill in the form keeping in mind those events that have occurred in the last year or since the last yearly examination are most important for this update. Medical Problems in the last year: Procedures/Surgeries/Blood Transfusions/Vaccines: Medications (doses)/Herbs/Supplements/Vitamins: Allergies: List all visits with specialists; last visit/next visit: Dr. Date: Dr. Date: Dr. Date: Review of Systems Please circle all that apply. If none, state none. GENERAL: weight changes fatigue weakness swollen glands night sweats chills hot flashes appetite changes sleep disturbances fever comments: HEAD: injury comments: headache EYES: visual changes comments: EARS: hearing loss comments: NOSE: bleeding comments: MOUTH: hair injury pain injury bleeding gums pattern changes infection discharge pain wax excess changes in smell tooth pain/dentures itch bleeding/injury congestion ringing discharge change in breath tongue pain/swelling comments: Please turn page THROAT: voice changes pain trouble swallowing swelling comments: NECK: swelling comments: pain CARDIO/PULMONARY: decreased mobility chest pain palpitations shortness of breath (positional, nighttimes, exertional) cough (mucous/blood) pain with breathing snoring comments: GASTROINTESTINAL: nausea vomiting diarrhea constipation pain heartburn rectal bleeding change in stool caliber comments: GENITOURINARY: urinary habit changes incontinence burning with urination stones nighttime urination blood/dark comments: Male: discharge sexual dysfunction testicle pain/swelling groin pain/swelling infection comments: Female: discharge painful intercourse periods absent/abnormal bleeding itching/burning comments: BREAST: pain lumps discharge swelling nipple changes comments: SKIN/NAILS: rash peeling itching redness infections pattern changes nail changes/ infections bruising comments: EXTREMETIES: skin growths color changes hair swelling pain temperature changes injury numbness/ tingling color changes joint pain/swelling/warmth loss of function comments: BACK: pain comments: stiffness injury NEUROPSYCHIATRIC: seizures blackouts tingling dizziness (position related) paralysis loss of feeling double vision slurred speech mood swings depression panic attacks anxiety hearing voices comments: Patient Signature:_____________________ Date __________ Provider Initial ___________ Thank you !