PATIENT NAME: ________________________________ DATE: __________
Review of Systems: Please circle all that apply.
Constitutional: Fever Chills
Eyes:
Blurriness
Pain
Ears/Nose/Throat:
Weight loss/gain
Discharge
Hearing loss
Night sweats
Weakness
Nasal drainage
Sore throat
Respiratory:
Earache
Genitourinary:
Abdominal pain
Incontinence
Cough
Wheezing
Reflux
Nausea
Skin lesions
Rash
Itching
Neurologic:
Fainting
Psychiatric:
Psychiatric history
Endocrine:
Diabetes
Hematologic:
Sleep:
Others:
Arthritis
Numbness
anxiety
Frequency
Kidney stones
Seizures
memory loss
Thyroid disease
Blood clotting problems
Excessive daytime sleepiness
Hepatitis type _______
Dysuria
Muscle weakness
depression
Hot and cold intolerance
Bleeding
Asthma
Hives
Focal Weakness
Anemia
Snoring
Palpitations Edema
Vomiting
Hematuria/blood in urine
Musculoskeletal: Joint pain Back problems
Skin:
Fatigue
Numbness
Shortness of breathe
Gastrointestinal:
Nausea
Itchiness
Cardio/Peripheral Vascular: Chest pain Difficulty breathing
Claudication
Fatigue Loss of appetite
HIV ______
Swollen glands
Witnessed apnea
High potassium
Low potassium
Cancer: ________________________________________________________________________
Past Medial History: Please circle any that apply.
High Cholesterol
Gout
Obesity
Dementia
Coronary artery disease
Atrial fibrillation
GI Bleeding
Congestive Heart failure
COPD
Osteoarthrosis
Stroke
Abdominal Aortic Aneurysm
Kidney transplant
Urinary tract infections
Seizures
Hypertension (high blood pressure)
Problems not mentioned in 2 sections above: _____________________________________________________
__________________________________________________________________________________________
Page 2
PATIENT NAME: ______________________________ DATE: __________________
Check any surgeries and list year.
__Appendectomy ______
___Kidney biopsy _______
___Tonsillectomy______ ___Prostate _______
__Gallbladder ______
___Hysterectomy _______
___Pacemaker________
__Breast biopsy ______
___Mastectomy ______
___Coronary artery bypass _________
___Other: _______________________________________________________________________________
Family History: please list family member and disease.
Kidney disease: ___________________________________________________________________________
Diabetes: ________________________________________________________________________________
Hypertension: ____________________________________________________________________________
Heart disease: ____________________________________________________________________________
Cancer: _________________________________________________________________________________
Other: __________________________________________________________________________________
Social History: please circle and list explanation.
Marital Status:
Employed:
Married
Full-time
Single
Divorced
Part-time
Separated
Partnered
Spouse deceased
Retired
Current or Previous Occupation: _______________________
Education:
High school diploma
Tobacco use: Non-smoker
Alcohol use: None
Drug use:
Never
GED
Some College
College graduate
Previous Smoker Smoker per day: 1-9
Occasional
10-19
20-39
40+
Everyday: ______________________________________
Previous: ____________________ Current: ________________________
Caffeine consumption:
Never
Some
Cups per day: _____
Filled out by: ___________________________________ Relationship: __________________