Fulton Family Health Associates, P.C.
2613 Fairway Dr, Suite C, Fulton, MO. 65251 Phone: (573) 642-1990 Fax: (573) 642-5089
Robert P. Pierce, M.D. Andra M. Walker, PA-C
Lisa J. Pierce, M.D. Ashlea E. Horstman, PA-C
Brice P. Windsor, D.O.
REVIEW OF SYSTEMS
Patient Name: _______________________________________
PLEASE CHECK ALL SYMPTOMS THAT APPLY:
CONSTITUTIONAL:
Weight Gain
Weight loss
Fatigue
Weakness
Fever
Chills
Night sweats
Loss of appetite
EYES:
Vision problems
Blurred vision
Double vision
Pain
Redness
Excessive tearing
Dry eyes
EARS, NOSE, MOUTH, THROAT:
Hearing loss
Ringing in ears
Ear pain
Discharge from ears
Vertigo
Runny nose
Nasal congestion
Bloody noses
Bleeding gums
Sore tongue
Sore throat
Hoarse voice
Mouth lesions
CARDIOVASCULAR:
Chest pain or pressure
Frequent irregular beats
Shortness of breath with exertion
Shortness of breath with laying flat
Wake up short of breath
Swelling in legs
RESPIRATORY:
Wheezing
Cough
Productive cough
Coughing up blood
GASTROINTESTINAL:
Abdominal pain
Nausea
Vomiting
Diarrhea
Constipation
Heart burn
Vomiting blood
Black/ tarry stools
Jaundice
Passing blood
Pain with swallowing
GENTITOURINARY:
MALES & FEMALES:
Burning with urination
Urgency
Frequency
Blood in urine
Frequent urination at night
Incontinence
Reduced stream
Urinary hesitancy
FEMALES:
Last menstrual period: _________
Absence of periods
Irregular periods
Heavy periods
Pain with periods
Vaginal discharge
Pain with intercourse
Bleeding after intercourse
Hot flashes
MALES:
Penile discharge
Penile lesions
Erectile dysfunction
MUSCULOSKELETAL:
Excessive joint pain
Joint swelling
SKIN AND/ OR BREAST:
Rash
Lumps
Changing moles
Date: ______/______/______
SKIN AND/ OR BREAST (cont.) :
Itching
Nail changes
Breast pain
Breast lumps
Nipple discharge
NEUROLOGICAL:
Headache
Fainting
Near fainting
Paralysis
Weakness
Tremor
PSYCHIATRIC:
Disorientation/ confusion
Nervousness
Restlessness
Anxiousness
Impaired recent memory
Impaired remote memory
Trouble sleeping
Increased sleep
Obsessions
Delusions
Hallucinations
ENDOCRINE:
Excessive urination
Excessive thirst
Cold intolerance
Heat intolerance
Excessive sweating
HEMATOLOGIC/ LYMPHATIC:
Easy bruising or bleeding
Bloody nose
Enlarged lymph nodes
ALLERGIC/ IMMUNOLOGIC:
Hives
Clear nasal discharge
Recurrent infections
Sneezing
QUESTIONS
Average drinks per day? _______________
MEN: Last time you had more than 5 drinks in one sitting? (circle one) : Never
> 1 year
< 1 year < 3 months
< 30 days
WOMEN: Last time you had more than 4 drinks in one sitting? (circle one) : Never
> 1 year
< 1 year < 3 months
< 30 days
In the past month, have you often been bothered by feeling depressed, down or hopeless? (circle one) : YES
NO
In the past month, have you often bothered by little interest or pleasure in doing things? (circle one) : YES
NO