Review of Systems Form | Contact ENT Partners of Texas

First Name*

Last Name

Email*

Phone*

Date

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