Adult History And Review Of Systems Questionnaire Page 3
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1
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3Do you CURRENTLY have? (IF YES, CHECK APPROPRIATE BOXES)
GENERAL
RESPIRATORY
GENITOURINARY
NEUROLOGICAL
Fatigue
Chronic Cough
Vaginal Discharge
Loss of Bowel Control
Fever
Decreased Exercise Tolerance
Menstrual Irregularities
Dizziness/Vertigo
Weight Gain >10 pounds
Difficulty Breathing
Difficulty Starting/Stopping
Headaches
Weight Loss >10 pounds
Coughing Up Blood
urinary Stream
Numbness/Tingling
SKIN
Sputum Production
Painful Urination
Passing Out
Nail Changes
Wheezing
Change in Urinary Stream
Seizures
New Lesions
BREAST
Increased Frequency
Tremor
Rash
Breast Mass
Blood in Urine
Skin Color Changes
Breast Pain
Loss of Bladder Control
HEENT
Nipple Discharge
Nighttime Urination
PSYCHIATRIC
Double Vision
Skin Changes
Urinary Retention
Anxiety
Eye Pain
CARDIOVASCULAR
Urethral Discharge
Change in Sleep Pattern
Eye Redness
Chest Pain
Impotence
Depression
Decreased Hearing
Leg Pains with walking
Penile Lesions
Hallucinations
Earache
Leg Swelling
Testicular Mass
Suicidal Thoughts
Ear Ringing
Night Awakening due to
Testicular Pain
ENDOCRINE
Nose Bleeds
trouble Breathing
Appetite Changes
Dry Mouth
Palpitations
Cold Intolerance
Hoarseness
Shortness of Breath
MUSCULOSKELETAL
Increased Thirst
Oral Ulcers
GASTROINTESTINAL
Decreased Range of Motion
Increased Urination
Sore Throat
Abdominal Pain
Joint Pain
Hair Changes
Change in Bowel Habits
Joint Redness
Sexual Dysfunction
NECK
Neck Pain
Constipation
Joint Swelling
HEMATOLOGY
Swollen Glands
Diarrhea
Joint Stiffness
Easy Bruising
Nausea
Muscle Wasting
Enlarged Lymph Nodes
Vomiting
Muscle Weakness
Prolonged Bleeding
Rectal Bleeding
Muscle Aches/Pains
Trouble Swallowing
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Parent category: Medical