Form

Review of Systems

Health Solutions PLLC
Full Name*
First Name Last Name
Birth Date*
Month Day Year
E-mail
In each section please follow the instructions. There are two sections for each body system. In the first of the two, check all those items that you have been experiencing on a regular basis or are concerned about. In the second section, you can elaborate or explain any item further if you wish (it is not necessary however).
CONSTITUTIONAL 'YES' Answers

I am generally healthy Recent unintentional weight change Fatigue Fevers
CONSTITUTIONAL-------- Explain "Yes" answers if needed
EYES 'YES' Answers

Wears glasses or contacts History of Eye injury Eye disease Concerning vision change Eye pain
EYES---- Explain "Yes" answers if needed
EARS/NOSE/THROAT 'YES' Answers

Hearing loss Ringing in ears Ear pain Nasal congestion Nose bleeds Bleeding gums Sore tongue Sores in mouth Bad breath Bad taste in mouth Sore throat Change in voice quality Swollen glands in neck
EARS/NOSE/THROAT--Explain "Yes" answers if needed
HEART 'YES' Anwers

Chest discomfort Shortness of breath with exertions Shortness of breath when lying down Palpitations Swelling in extremities
HEART-Explain "Yes" answers if needed
LUNGS 'YES' Answers

Chronic cough Unusual intermittent cough Coughing up blood Wheezing Shortness of breath
LUNGS-Explain any answers if needed
GASTRO-INTESTINAL 'YES' Answers

Loss of appetite Nausea Vomiting Belly pain Heartburn Constipation Diarrhea Painful bowel movements Blood in stool or on tissue
GASTRO-INTESTINAL-Explain any answers if needed
GENITAL/URINARY 'YES' Answers

Frequent urination Discomfort with urination Blood in urine Change in force of stream Dribbling or incontinence of urine Sexual difficulties Males: testicle pain Females: Severe menstrual cramping Females: Irregular periods Females: Vaginal discharge
GENITAL/URINARY Explain any answers if needed
MUSCULO-SKELETAL 'YES' Answers

Joint pain Joint stiffness Joint swelling Muscle weakness Muscle pain Muscle cramps Back pain
MUSCULO-SKELETAL Explain any answers if needed
SKIN and BREAST 'YES' Answers

Rash Itching Change in skin color Varicose veins Change in hair Change in nails Breast pain Discharge or drainage from nipple
SKIN/BREAST Explain any answers if needed
NEUROLOGICAL 'YES' Answers

Bothersome headaches Lightheadedness Dizziness Numbness or tingling sensations Fainting or loss of consciousness Tremors Loss of function of any body parts
NEUROLOGICAL Explain any answers if needed
PSYCHOLOGICAL 'YES' Answers

Memory loss Confusion Nervousness/anxiety Panic attacks Depression Insomnia
PSYCHOLOGICAL Explain any answers if needed
ENDOCRINE 'YES' Answers

Excessive thirst Excessive volume of urination Not tolerant to cold Not tolerant to heat Excessively dry skin More oily skin (change from previous) Acne (newer onset) Excessively low blood pressure Hair loss
ENDOCRINE Explain any answers if needed
BLOOD/LYMPH 'YES' Answers

Enlarged lymph glands Painful lymph glands Excessive bruising Slow to heal cuts/sores
BLOOD/LYMPH Explain any answers if needed
ALLERGY/IMMUNITY 'YES' Answers

Recurrent hives History of serious allergic reaction
ALLERGY/IMMUNE SYSTEM Explain any answers if needed
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Review of Systems