Medicine Complete Physical Exam Form Page 2
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4MEDICINE COMPLETE PHYSICAL EXAM
REVIEW OF SYSTEM
Yes
No
Comments
Shortness of breath with walking or lying
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flat?
RESPIRATORY
Yes
No
Do you have chronic or frequent coughs?
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Spitting up blood?
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Shortness of breath?
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Asthma or wheezing?
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GASTROINTESTINAL
Yes
No
Do you have loss of appetite?
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Change of bowel movements?
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Nausea or vomiting?
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Frequent diarrhea?
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Painful bowel movements or constipa-
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tion?
Rectal bleeding or blood in stool?
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Abdominal pain or heartburn?
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Peptic ulcer disease?
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Any history of liver disease or hepatitis?
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Have you ever had a endoscopy or
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colonoscopy before?
GENITOURINARY
Yes
No
Do you have frequent urination?
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Burning or painful urination?
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Blood in urine?
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Change in force of strain when urinating?
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Incontinence or dribbling?
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Kidney stones?
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Sexual difficulty?
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Male- testicule pain?
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Female- pain with periods?
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Female- irregular periods?
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Female- vaginal discharge?
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Female- How many pregnancies?
Pregnancies: ______
Female- How many miscarriages?
Miscarriages: ______
Female- Any abnormal PAP smears?
When was your last PAP smear? ______________
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MUSCULOSKELETAL
Yes
No
BERGEN KIDNEY CENTER, P.C.
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