Review of Systems: Have you had trouble with any of the following:

Cardiovascular: Present Poor Circulation High Blood Pressure Aortic Aneurism Heart Disease Heart Attack Chest Pain High Cholesterol Pace Maker Jaw Pain Irregular Heartbeat Swelling of Legs No Past Respiratory: No Asthma Tuberculosis Shortness of Breath Emphysema Cold/Flu Cough/Wheezing Present No Past Allergic/Immunologic: Present Hives Immune Disorder HIV/AIDS Allergy Shots Cortisone Use No Past

No

No

Gastrointestinal: Ears/Nose/Throat: Present Dizziness Hearing Loss Sinus Infection Nosebleed Sore Throat Difficulty Swallowing Bleeding Gums No Past Present No Gallbladder Problems Bowel Problems Constipation Liver Problems Ulcers Diarrhea Nausea/Vomiting Bloody Stools Poor Appetite

No Past

No

Genitourinary: Present Kidney Disease Lower Side Pain Burning Urination Frequent Urination Blood in urine Kidney Stone

No Past

No

Eyes: Present Glaucoma Double Vision Blurred Vision No Integumentary: Present Skin Ulcers Skin Disease Eczema Psoriasis Rashes No Past No Psychiatric: Present Depression Anxiety Disorder Unusual Stress

No Past

No

Musculoskeletal: Present Gout Arthritis Joint Stiffness Muscle Weakness Osteoporosis Broken Bones Joints Replaced

No Past

No

Hematologic/lymphatic: Present Hepatitis Blood Clots Cancer Easy Bruising Easy Bleeding Fevers/Chills/Sweats

No Past

No Past

No

Endocrine: Present No Past Thyroid Disease Diabetes Hair Loss Menopausal Menstrual Problems

Neurologic: Present Stroke Seizures Head Injury Brain Aneurysm Numbness Severe Headaches Pinched Nerves Parkinson's Disease Carpal Tunnel Spinning/Balance

No Past

No

No

Constitutional: Present Weight Loss/Gain Energy Level Problem Difficulty Sleeping

No Past

No