Review of Systems – Medical History Review of Systems – Medical History Patient first name(Required)Last name(Required)Email(Required) Enter Email Confirm Email Date of Birth(Required)Date(Required) MM slash DD slash YYYY Review of SystemsCONSTITUTIONAL SYMPTOMSWeight Change Yes No Chills/fever Yes No Fatigue Yes No OtherHEAD AND NECK SYMPTOMSHeadaches Yes No Facial Pain Yes No Neck Pain Yes No Neck Pain radiating to arms Yes No OtherSKIN SYMPTOMSHives Yes No Itching Yes No Rash Yes No OtherHEMATOLOGICAL SYMPTOMSBleeding or Bruising Yes No OtherRESPIRATORY SYMPTOMSShortness of breath Yes No Infections Yes No OtherGASTROINTESTINAL SYMPTOMSDifficulty swallowing Yes No Abdominal pain Yes No Ulcer disease Yes No Liver disease Yes No Bowel problems Yes No OtherENDOCRINE SYMPTOMSDiabetes Yes No Hot or cold intolerance Yes No OtherCARDIOVASCULAR SYMPTOMSHeart disease Yes No Angina – Chest pain Yes No Irregular heartbeat Yes No OtherVISUAL SYMPTOMSBlurry vision Yes No Double vision Yes No Loss of vision Yes No Seeing flashing lights Yes No OtherEARS, NOSE, AND THROAT SYMPTOMSHearing loss Yes No Ringing in ears Yes No Vertigo, dizziness, lightheadedness Yes No Taste disturbance Yes No Smell disturbance Yes No OtherGENITOURINARY SYMPTOMSUrinary frequency Yes No Urinary urgency Yes No Urinary loss of control Yes No Urinary tract infection Yes No Sexual dysfunction Yes No OtherMUSCULOSKELETAL SYMPTOMSBack pain Yes No Pain radiating to legs Yes No Neck pain Yes No Pain radiating to arms Yes No Joint pains Yes No Pain in arms/hands Yes No Pain in legs/feet Yes No Muscle weakness Yes No Muscle pain/aches Yes No Muscle twitches/fasciculations Yes No Muscle cramps Yes No OtherPSYCHOLOGICAL SYMPTOMSAnxiety Yes No Depression Yes No Hallucinations Yes No OtherGYNECOLOGICAL SYMPTOMSOtherSLEEP SYMPTOMSSnoring Yes No Gasping at night Yes No Insomnia Yes No Daytime sleepiness Yes No Restless legs Yes No OtherNEUROLOGICAL SYMPTOMSHeadache Yes No Visual symptoms Yes No Facial pain Yes No Memory lapse or loss Yes No Confusion/disorientation Yes No Generalized pain Yes No Localized pain Yes No Where? Head Neck Arms Torso Legs Numbness Yes No Where? Head Neck Arms Torso Legs Fatigue – feeling tired Yes No Tremor Yes No Unsteady walking/wobbly Yes No Falls Yes No Convulsions/seizures Yes No Fainting/passing out Yes No Stroke Yes No Spinal cord disease Yes No Head injury/concussion Yes No with loss of consciousness Yes No OtherPast Medical HistoryDoes the patient have a history of any of the following:Hypertension Yes No Liver disease Yes No Kidney disease Yes No Seizure disorder Yes No Parkinson's disease Yes No Autoimmune disease Yes No Psychiatric disorder Yes No Gallbladder disease Yes No Diabetes Mellitus Yes No Type of Diabetes Type 1 Type 2 Heart disease Yes No Type of Heart Disease Coronary artery disease/Angina Atrial fibrillation Heart attack Thyroid disease Yes No Type of Thyroid Disease Hyper- Hypo- Hashimoto’s Gastrointestinal disorder Yes No Type of disorder GI Bleed Reflux/GERD Bowel problems Lung disease Yes No Type of Lung disease Asthma COPD Sleep disturbances Yes No Type of disturbance Sleep apnea Narcolepsy Insomnia Headaches Yes No Type of headaches Migraines Other headache Muscle disease Yes No Type of disease Myasthenia gravis Fibromyalgia Stroke/TIA Yes No Type of stroke Carotid disease/stenosis Intracranial hemorrhage Nerve disease Yes No Type of disease Neuropathy Nerve pain Sciatica Radiculopathy Yes No Type of radiculopathy Cervical Lumbar Thoracic Surgery Yes No List SurgeriesBlood disorder Yes No Bladder problems Yes No Bowel problems Yes No Multiple sclerosis Yes No Vision loss/double vision Yes No Memory loss Yes No Endocrine disease Yes No Cancer Yes No Arthritis Yes No Gynecologic problems Yes No Family Medical HistoryPlease list any family history pertaining to your parents and siblings:Hypertension Yes No Heart disease Yes No Cancer Yes No Gastrointestinal disorder Yes No Liver disease Yes No Kidney disease Yes No Lung disease Yes No Seizures Yes No Eye disease Yes No Sleep disorder Yes No Diabetes Yes No Stroke Yes No Memory loss Yes No Multiple Sclerosis Yes No Autoimmune disease Yes No Thyroid disease Yes No Parkinson's disease Yes No Headaches/Migraines Yes No Nerve disease Yes No Muscle disease Yes No Other Illnesses Yes No Other IllnessesPlease list…Unknown History My family history is unobtainable due to being adopted My family history is unknown Social HistoryYou are… Right-handed Left-handed What are your exercise habits? Good exercise habits (more than 3 days a week) Poor exercise habits Do you drink or use caffeine? Yes No What is your occupational status? Full-time Part-time Homemaker Currently on disability Unemployed Retired Student Military Service Your occupationDo you use tobacco products? Current, every day smoker Current, some days smoker Former smoker Have never smoked Unknown What is your marital status? Currently married Domestic partner Single Separated Divorced Widowed Do you drink alcohol? Yes, socially Yes, 2 or fewer drinks per day Yes, 2 or more drinks per day No Rev 8.8.2022NameThis field is for validation purposes and should be left unchanged.