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Review of Systems Adult Form
Crystal Hays
2020-06-24T13:25:53-05:00
REVIEW OF SYSTEMS – ADULT
First Name
*
Last Name
Email
*
Phone
*
Date
MM slash DD slash YYYY
Patient Name
First
Last
Constitutional
Fever
Yes
No
Daytime sleepiness
Yes
No
Weight loss (unintentional)
Yes
No
Weight gain (unintentional)
Yes
No
Eyes
Itchy eyes
Yes
No
Eye drainage
Yes
No
Ears/Nose/Throat
Decreased hearing
Yes
No
Ringing in ears
Yes
No
Nosebleeds
Yes
No
Nasal congestion
Yes
No
Sneezing
Yes
No
Itchy nose
Yes
No
Itchy throat
Yes
No
Frequent sore throat
Yes
No
Prolonged hoarseness
Yes
No
Cardiovascular
Chest pain
Yes
No
Palpitations
Yes
No
Respiratory
Cough (chronic)
Yes
No
Snoring
Yes
No
Gastrointestinal
Difficulty swallowing
Yes
No
Heartburn
Yes
No
Genitourinary
Blood in urine
Yes
No
Musculoskeletal
Muscle weakness
Yes
No
Joint pain/stiffness
Yes
No
Back pain
Yes
No
Integumentary
Rashes
Yes
No
Eczema
Yes
No
Neurological
Frequent headaches
Yes
No
Difficulty sleeping
Yes
No
Problems with balance
Yes
No
Hematologic/Lymphatic
Easy bruising
Yes
No
Excessive bleeding
Yes
No
Enlarged lymph nodes
Yes
No
Endocrine
Excessive appetite
Yes
No
Heat/cold intolerance
Yes
No
Excessive sweating
Yes
No
Allergic/Immunologic
Problems with anesthesia
Yes
No
Psychiatric
Depression
Yes
No
Memory loss
Yes
No
Difficulty speaking
Yes
No
Printed name of person completing form
First
Last
Relationship to patient
Δ
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