Review of Symptons

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					Review of Systems
Patient name:_______________________________ Date of Birth: _________________
                                Please check Yes/No as related to your current issues
Constitutional Systems               YES    NO                  Gastrointestinal                     YES   NO
Fever                                                           Swallowing difficulty
Excessive weight loss or gain                                   Vomiting/Heartburn
Fatigue                                                         Constipation/diarrhea
                                                                Nausea/vomiting
Skin
Rashes of color or changes                                      Genitourinary
Itching or dryness                                              Urinary frequency
Hair or nail changes                                            Urinary pain or blood
Changing moles                                                                     Males:
                                                                Discharge, lesions or masses
Eyes                                                                               Females:
Loss of vision                                                  Currently pregnant
Distorted vision or haloes                                      Currently breast feeding
Fluctuating vision                                              Breast masses or discharge
Eye pain or soreness                                            Vaginal bleeding/discharge
                                                                Pelvic pain
Ears, Nose Mouth Throat                                         Irregular Menstruation
Hearing difficulty
Ringing or dizziness                                            Musculoskeletal
Sinus congestion                                                Joint pain, swelling, redness
Runny nose/post-nasal drip                                      Muscle pain or cramps
Nose bleeds
Dryness/hoarseness                                              Neurological
                                                                Headaches/migraines
Cardiovascular                                                  Numbness or tingling
Chest pains or palpitations                                     Weakness or paralysis
Other                                                           Fainting or blackouts
                                                                Slurred speech
Respiratory
Cough                                                           Psychiatric
Shortness of breath                                             Anxiety
Other                                                           Depression
                                                                Other
Endocrine
Heat or cold intolerance                                        Hematological/Lymphatic/Immunology
Excessive thirst or hunger                                      Easy bruising/bleeding
                                                                Blood transfusions
Other Symptoms:________________________                         Swollen lymph nodes
_______________________________________


Signed:___________________________________ Reviewed: ____________________ Date: ____________


                                 Adrienne E. Stewart, M.D., Board Certified Dermatologist
                                             3300 East 1st Avenue, Suite 400
                                                    Denver, CO 80206

				
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posted:10/26/2011
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