Medicine Complete Physical Exam Form Page 3
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4MEDICINE COMPLETE PHYSICAL EXAM
REVIEW OF SYSTEM
Yes
No
Comments
Do you have joint pain?
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Joint stiffness or swelling?
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Weakness of muscles or joints?
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Muscle pain or cramps?
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Back Pain?
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Cold extremities?
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Difficult walking?
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INTEGUMENTARY (skin, breast)
Yes
No
Do you have any rash or itching?
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Change in skin color?
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Change in hair or nails?
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Varicose veins?
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Breast pain, lump or discharge?
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NEUROLOGICAL
Yes
No
Do you have frequent or recurring headaches?
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Lightheaded or dizziness?
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Convulsion or seizures?
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Numbness or tingling sensations?
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Tremors?
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Paralysis?
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Stroke?
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Head injury?
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PSYCHIATRIC
Yes
No
Do you have memory loss or confusion?
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Nervousness?
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Depression?
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Insomnia?
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ENDOCRINE
Yes
No
Do you have glandular or hormone problems?
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Thyroid disease?
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Diabetes?
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Excessive thirst or urination?
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Heat or cold intolerance?
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HEMATOLOGIC/LYMPHATIC
Yes
No
Are you slow to heal after cuts?
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BERGEN KIDNEY CENTER, P.C.
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