Patient Review of Systems Form by 8JMwzS

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									                                        Review of Systems
                                      (Check All That Apply)
Name: __________________________
Date: __________________________
Acct No: ________________________


  Constitutional                                      Musculoskeletal
        Fever                                              Muscle Pain
        Chills                                             Joint Pain
        Feeling Poorly                                     Joint Swelling
        Feeling Tired                                      Joint Stiffness
        Recent Weight Gain ____lbs                   Integumentary
        Recent Weight Loss ____lbs                         Skin Rash
  Eyes                                                      Skin Wound
        Blurry Vision                                      Itching
        Glaucoma                                           Jaundice
        Eye Infections                               Neurological
        Dry Eyes                                           Confusion
        Red Eyes                                           Numbness
  ENT                                                       Dizziness
        Ringing in the Ears                                Fainting
        Throat Clearing                                    Headaches
        Sore Throat                                  Psychiatric
        Hoarseness                                         Suicidal
        Mouth Sores                                        Depression
  Cardiovascular                                            Anxiety
        Heart Rate is Slow                                 Sleep Disturbances
        Heart Rate is Fast                           Endocrine
        Chest Pain                                         Heat Intolerance
        Palpitations                                       Excessive Thirst
        Lower ext Edema                                    Cold Intolerance
  Respiratory                                               Excessive Urination
        Shortness of Breath                          Gastrointestinal
        Wheezing                                           Poor Appetite
        Cough                                              Difficulty Swallowing
        Shortness of Breath on Exertion                    Heartburn
        Spitting up Blood                                  Diarrhea
  Genitourinary                                             Rectal Bleeding
        Dysuria                                            Nausea
        Incontinence                                       Vomiting
        Testicular Pain                                    Bloating
        Blood in Urine                                     Abdominal Pain
        Kidney Stones                                      Black Tarry Stools
        Abnormal Vaginal Bleeding                          Belching
        Genital Lesion                                     Regurgitation
  Heme/Lymph                                                Constipation
        Easy Bleeding                                      Recent Change in Bowel Habits
        Easy Bruising
        Swollen Glands

								
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