Review of Systems.
(Please review and check all that apply)
GENERAL: □ Fever □ Weight gain □ Fatigue
EYES: □ Visual changes □ Light sensitivity □ Double vision □ Blurred vision
ENT: □ Decreased hearing □ Snoring
RESPIRATORY: □ Cough □ Shortness of breath
CARDIOVASCULAR: □ Chest pain □ Rapid heart beat □ Irregular heartbeat
GASTROINTESTINAL: □ Nausea □ Swallowing difficulty □ Diarrhea □ Constipation
GENITOURINARY: □ Urgency to urinate □ Frequent urination
MUSCULOSKELETAL: □ Muscle cramps □ Spasms
NEUROLOGICAL: □ Headaches □ Seizures □ Dizziness □ Double vision □ Numbness □ Change
in speech □ Sudden weakness in arms and/or legs □ Excessive daytime sleepiness □ Difficulty
falling a sleep □ Frequent night time awakening □ Memory problems □ Confusion □ Fainting /
passing out spells □ Blackout spells □ Tremors
ENDOCRINE: □ Fatigue □ Heat or cold intolerance □ Insulin use □ Prednisone use □ Excessive
thirst □ Frequent urination □ Low blood sugar
HEMATOLOGIC: □ History of blood clots □ Easy bruising □ Coumadin use SKIN: □ Color
change □ Temperature Change □ Changes in hair or nails
PSYCHIATRIC: □ Agitation □ Irritability □ Depression □ Anxiety □ Nervousness
ALLERGY: □ Itching □ Environmental □ Severe tropical sensitivties
SKIN: □ Rashes □ Hives □ Color changes
MUSCULOSKELETAL: □ Joint pain □ Joint swelling □ Cramps □ Stiffness
INITIAL VISIT:
I have read the statemenst and answers to the above questions. I affirm that they are complete to the best of my knowledge
and belief.
Patient Signature:_____________________________________Date:___________________________
Physician Signature:___________________________________Date:___________________________
FOLLOW UP:
Patient Signature:_____________________________________Date:____________________________
Physician Signature:___________________________________Date:____________________________