Spring Valley Family Medicine
Health Review Form—Please answer yes or no to each question
Please answer questions below based on things you have experienced RECENTLY
Name:_______________________
Date of Birth:
YES
General
Fevers
Chills
Abnormal weight gain
Abnormal weight loss
Fatigue
Eyes
Decreased vision
Double vision
Eye pain
Ears/Nose/Throat
Decreased hearing
Difficulty swallowing
Dizziness
Hoarseness
Sinus congestion
Sore throat
Runny nose
Ear ache
Cardiovascular
Chest pain
Fainting
Pain in legs with exertion
Palpitations
Shortness of breath at night
Shortness of breath when lying down
Shortness of breath with exertion
Swelling of hands or feet
Respiratory
Chest pain
Shortness of breath
Cough
Wheezing
Gastrointestinal
Abdominal pain
Blood in stools
Change in bowel habits
Constipation
Diarrhea
Frequent indigestion
Nausea
Vomiting
Vomiting blood
Heartburn
Difficulty swallowing
Genitourinary
Abnormal vaginal discharge
Decreased urine
Painful urination
Blood in urine
Incontinence
Up at night to urinate more than usual
Urinating more frequently than usual
Problems with urine stream
NO
____________
YES
Heavy periods
Severe menstrual cramps
Musculoskeletal
Back pain
Neck pain
Joint pain
Joint swelling
Muscle pain
Muscle weakness
Skin
Rash
Change in moles
Suspicious lesions
Neurologic
Dizziness
Fainting
Headaches
Numbness
Weakness
Seizures
Tremors
Psychiatric
Anxiety
Depression
Suicidal thinking
Eating disorder
Endocrine
Cold intolerance
Excessive urination
Overly thirsty
Heat intolerance
Significant weight change
Heme/Lymphatic
Abnormal bruising
Bleeding
Enlarged lymph nodes
Allergic/Immunologic
Bee sting allergy
Food allergies
Hives (urticaria)
Persistent infections
Breast
Left breast lump
Right breast lump
Nipple discharge
Bloody discharge from nipple
Breast pain
Abnormal mammogram
Breast enlargement
12/04/2013
NO