Elbow Patient History Form Page 3
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8Pease tell us your height and weight:
Height
: ___ feet ____ inches
Weight
: _____ pounds
Referring Physician (first and last name): _____________________________________________
Address:
_____________________________________________
_____________________________________________
Review of Systems
(Check any problems that apply in each category)
General
Gastrointestinal
recent weight gain
heartburn / indigestion
recent weight loss
difficulty swallowing
appetite change
stomach pains
difficulty sleeping
ulcers
None
nausea / vomiting
Cardiovascular
diarrhea
chest pain
hemorrhoids
heart attack
rectal bleeding
palpitations (irregular heart beat)
black bowel movements
heart failure
change in bowel habits
edema (leg swelling)
constipation
high blood pressure
frequent laxative use
leg cramps with walking
jaundice or hepatitis
None
liver trouble
Pulmonary
gallbladder problems
None
shortness of breath
cough
Neurologic
sputum
headaches
bronchitis
dizziness
asthma
blackouts
night sweats
numbness and tingling
None
paralysis
Endocrine & Metabolic
convulsions / seizures
sugar diabetes
coordination trouble
None
goiter
thyroid problem
Genitourinary
sterility
burning on urination
cholesterol / lipid problem
frequency of urination
None
difficulty starting urine
Hematopoietic / Lymphatic
wetting pants or bed
anemia
bloody urine
lymph node enlargement
sexual difficulties
None
bleeding problem
frequent infections
Psychiatric
None
anxiety
Musculoskeletal
depression
joint pain
been seen by a psychiatrist
None
joint swelling or warmth
joint stiffness
muscle pain
weakness
back pain
joint deformity
None
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Parent category: Medical