SYMPTOM CHECKLIST _REVIEW OF SYSTEMS_ by hcj

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									SYMPTOM CHECKLIST (REVIEW OF SYSTEMS)

Symptoms Fever/night sweats/weight change Skin rashes Easy bruising/bleeding Depressed mood Difficulty sleeping Shortness of breath Chest pain Nausea/vomiting Loss of bowel/bladder control Sexual dysfunction Numbness/tingling Weakness

Please circle NO or YES. If YES, please explain below NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES (if yes, discuss with doctor) NO YES (if yes, discuss with doctor)

Medical problems (including surgeries):

Medications (with dosages):

Drug allergies:

Family history (what medical problems run in your immediate family?):

Alcohol use: NO

YES

If YES, how much?

Tobacco use: NO

YES

If YES, how much?

Other recreational drug use: NO YES

If YES, what drug and how much?

What do you do for a living? (brief job description)

____________________________________ MD Signature Date


								
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