System Review


Name *
Birthdate *
Account Number
Please answer each of the following. For any answered YES, please explain.

Systemic / HEENT

Fatigue
Weight Gain / Loss
Insomnia
Dry Eyes
Dry Mouth
Oral Ulcers

GI

Heartburn
Abdominal Pain
Constipation (frequent)
Diarrhea (frequent)
Rectal Bleeding

GU / GYN

Urinary Burning
Urinary Bleeding
Menstrual Irregularity
Menopause

Cardiovascular / Pulmonary

Edema (fluid retention)
Chest Pain
Palpitations
Shortness of Breath
Cough
Wheezing

Neurologic / Psychiatric

Numbness / Tingling / Burning Sensation
Poor Balance
Muscle Weakness
Frequent Headache
Anxiety
Depression

Hematologic / Endocrinologic / Dermatology

Easily Bruises
Enlarged Lymph Nodes
Heat Intolerance
Cold Intolerance
Hair Loss
Rash

MS - SK

Joint Swelling
Joint Pain
Muscle Pain
Broken Bones
Neck / Back Pain

Social History

# Alcoholic Beverages / Week
# Cigarettes / Day
# Cigars / Day
Describe Regular Exercise Program
Sources of Stress

Past History

List any hospitalizations, new diagnoses, doctor visits since last seen in our office
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