Review of Symptoms
Name____________________________________
Birth Date_________ Date of Service__________
Please circle or fill in any of the following that pertain and indicate the year of occurrence:
General
Fever
Chills
Sweats
Decreased/ increased appetite
Extreme fatigue
Weakness
Malaise
Weight change (gain/ loss)
Sleeping problems
Eyes
Vision loss (Right/Left/Both)
Irritation
Blurring
Pain
Halos
Discharge
Light sensitivity
ENT
Ringing in ears
Ear discharge
Ear pain
Decreased hearing
Nasal congestion
Nosebleeds
Difficulty swallowing
Hoarseness
Sore throat
Cardiovascular
Difficulty breathing at night
Fainting/ near fainting
Chest pain/ discomfort
Racing/skipping beats
Fatigue
Lightheadedness
Shortness of breath with activity
Palpitations
Swelling of hands/feet
Leg cramps when walking
Blue lips/nails
Weight gain
Respiratory
Cough
Shortness of breath
Coughing up blood
Chest discomfort
Wheezing
Excessive sputum
Snoring
Asthma
Gastrointestinal
Appetite increase/decrease
Indigestion
Vomiting blood
Nausea
Vomiting / Diarrhea
Yellow skin color
Gas/ Bloating
Abdominal pain
Hemorrhoids
Change in bowel habits
Constipation
Dark, tarry stools
Bloody stools
Genitourinary
Foul urinary discharge
Blood in urine
Urinary frequency
Kidney pain
Trouble starting stream
Painful urination
Urinating at night
Inability to empty bladder
Genital sores
Lack of sexual drive
Unusual urine color
Male Only Genitourinary
Erectile Problems
Female Only Genitourinary
Pelvic pain
Heavy periods
Missed periods
Irregular vaginal bleeding/periods
Musculoskeletal
Muscle cramps/ aches
Back/Joint pain
Joint fluid
Stiffness
Muscle weakness
Arthritis
Gout
Loss of strength
Dermatological
Excessive sweating/Night sweats
Suspicious lesions/moles
Changes in nails
Dryness
Poor wound healing
Unusual hair distribution
Skin cancer
Itching
Changes in color of skin
Rash
Intermountain Internal Medicine
Neurological
Difficulty concentrating
Poor balance
Headaches
Coordination difficulty
Numbness
Inability to speak
Tingling
Brief paralysis
Visual disturbances
Seizures
Weakness
Sensation of room spinning
Tremors
Fainting
Excessive daytime sleeping
Memory loss
Psychological
Sense of great danger
Anxiety / Depression / Sadness
Thoughts of suicide
Mental problems
Eating disorder
Thoughts of violence
Frightening sounds / visions
Difficulty sleeping
Endocrine
Excessive hunger
Cold/ heat intolerance
Excessive urination
Excessive thirst
Weight change (gain/loss)
Hematological
Enlarged lymph nodes
Bleeding
Skin discoloration
Abnormal bruising
Fevers
Allergy
Persistent infections
Hives
Rash
Seasonal allergies
HIV exposure
Other symptoms/ concerns?
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