Review Of Systems. 1. General Weight Weight 1 year ago Maximum weight When Height Fatigue/Weakness Y P N Fever/Chills Y P N

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Review Of Systems Y N P a condition you have now a condition you have NEVER had a condition you have had in the past Responses and Comments: 1. General Weight Weight 1 year ago Maximum weight When Height Fatigue/Weakness Y P N Fever/Chills Y P N 2. Skin Rashes Y P N Eczema, hives, acne, boils (circle) Y P N Itching Y P N Color change Y P N Lumps Y P N Night sweats Y P N Dryness/Moistness (circle) Y P N Nail changes Y P N Changes in mole Y P N Skin cancer Y P N 3. Head Headache Y P N Head injury (when) Y P N Dizziness Y P N Hair loss Y P N 4. Eyes Impaired vision Y P N Glasses/Contacts Y P N Eye pain Y P N Tearing or dryness (circle) Y P N Double vision Y P N Glaucoma Y P N Cataracts Y P N Blurring Y P N Itching Y P N Redness Y P N Discharge Y P N Blind spot Y P N Pg. 1 of 6

5. Ears Impaired hearing Y P N Earache Y P N Discharge Y P N Infections Y P N 6. Nose and Sinuses Frequent colds Y P N Nose bleeds Y P N Stuffiness/Post nasal drip (circle) Y P N Hay fever Y P N Sinus problems Y P N 7. Mouth and Throat Frequent sore throat (how many times a year) Y P N Sore tongue/mouth Y P N Gum problems Y P N Hoarseness of voice (since when) Y P N Dental cavities Y P N Loss of taste Y P N 8. Neck Pain Y P N Lumps/Swollen glands (circle) Y P N Goiter Y P N 9. Respiratory Cough Y P N Sputum (indicate color) Y P N Wheezing Y P N Asthma Y P N Bronchitis Y P N Pneumonia Y P N Pleurisy Y P N Emphysema Y P N Difficulty breathing Y P N Pain on breathing Y P N Shortness of breath Y P N Shortness of breath at night Y P N Shortness of breath lying down Y P N Tuberculosis Y P N Tuberculin test Y P N Last chest X-ray 10. Breasts Do you do self-exams? Y P N Lumps Y P N Pain or tenderness Y P N Nipple discharge Y P N Pg. 2 of 6

11. Cardiovascular Heart disease Y P N Angina Y P N High blood pressure Y P N Murmurs Y P N Rheumatic fever Y P N Chest pain Y P N Swelling in ankles Y P N Palpitations, fluttering Y P N Cyanosis Y P N Past ECG Y P N Other heart tests 12. Gastrointestinal Trouble swallowing Y P N Heartburn Y P N Change in appetite or thirst (circle) Y P N Nausea Y P N Vomiting Y P N Vomiting blood Y P N Bowel movements how often? Is this a change? Y N Blood in stool Y P N Belching or passing gas Y P N Jaundice (yellow skin) Y P N Liver disease Y P N Gall bladder disease Y P N Ulcer Y P N Indigestion Y P N Diarrhea Y P N Rectal bleeding Y P N Hemorrhoids Y P N Black, tarry stool Y P N Abdominal pain Y P N Food allergy Y P N Hernias Y P N 13. Urinary Pain on urination Y P N Increased frequency Y P N Frequency at night Y P N Inability to hold urine Y P N Frequent infections Y P N Kidney stones Y P N Blood in urine Y P N Urgency Y P N Hesitancy Y P N Pg. 3 of 6

14. Male Reproductive Hernias Y P N Testicular pain Y P N Testicular masses Y P N Are you sexually active? Y P N Sexual difficulties Y P N Venereal diseases Y P N Discharge or sores Y P N Sexual preference: Heterosexual Y P N Bisexual Y P N Homosexual Y P N 15. Female Reproductive Age menses began Average number of days Length of cycle Bleeding between periods Y P N Are cycles regular Y P N Pain during intercourse Y P N Painful menses Y P N Excessive flow Y P N PMS Y P N Birth control? Y P N What type? Number of pregnancies Number of live births Number of miscarriages Number of abortions Are you sexually active? Y P N Sexual difficulties Y P N Venereal disease Y P N Sexual preference: Heterosexual Y P N Bisexual Y P N Homosexual Y P N Last menstrual period Vaginal discharge Y P N Vaginal itching Y P N Difficulty conceiving Y P N Last PAP smear (date) 16. Musculoskeletal Joint pain or stiffness Y P N Arthritis Y P N Broken bones Y P N Muscle spasms or cramps Y P N Weakness Y P N Joint swelling Y P N Backache Y P N Pg. 4 of 6

17. Peripheral Vascular Deep leg pain Y P N Cold hands/feet Y P N Varicose veins Y P N Thrombophlebitis Y P N Leg cramps Y P N Extremity numbness Y P N Extremity coldness Y P N Extremity swelling Y P N Extremity ulcers Y P N 18. Neurologic Fainting Y P N Seizures/Convulsions Y P N Paralysis Y P N Muscle weakness Y P N Numbness or tingling Y P N Loss of memory Y P N Involuntary movement Y P N Loss of balance Y P N Speech problems Y P N 19. Endocrine Heat or cold intolerance (circle) Y P N Thyroid trouble Y P N Excessive thirst Y P N Excessive hunger Y P N Excessive urination Y P N Excessive sweating Y P N Diabetes Y P N Hypoglycemia Y P N Hormone therapy Y P N 20. Blood/Lymphatic Anemia Y P N Easy bleeding or bruising Y P N Past transfusions Y P N Lymph node swelling Y P N 21. Allergic history Drug sensitivity Y P N Reaction to vaccine Y P N Please list any allergies: 22. Emotional Depression Y P N Mood swings Y P N Anxiety/nervousness/tension (circle) Y P N Phobias Y P N Alcohol/drug abuse Y P N Insomnia Y P N Pg. 5 of 6

23. Hobbies/habits Please answer yes (Y) or no (N) Do you eat three meals a day? Y N Do you watch television? Y N Do you awake rested? Y N How many hours a day? Do you sleep well? Y N Do you read? Y N Do you average 6-8 hrs. sleep? Y N How many hours a day? Do you enjoy your work? Y N Do you exercise? Y N Do you take vacations? Y N What forms? Have you been treated for drug dependence? Y N Do you use recreational drugs? Y N Do you use alcoholic beverages? Y N Have you been treated for alcoholism? Y N Pg. 6 of 6

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