Form #10ll - Patient History Form Page 2

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SYSTEM REVIEW
Check all applicable symptoms. If not applicable, please check N/A
General Health (Constitutional):
r
Recent weight changes
r
Fever
r
Tiredness
r
N/A
Eyes:
r
Vision Change
r
Loss of Vision
r
Double Vision
r
Pain
r Left r Right r Both
r Left r Right r Both
r Left r Right r Both
r Left r Right r Both
Burning
Discharge/Tearing
r
r
r Left r Right r Both
r Left r Right r Both
r N/A
Ears, Nose, Mouth, Throat: (problems other than reason for today’s visit)
Ringing in ears
Hearing loss
Earache
Draining, discharge form ear
r
r
r
r
r
Itchy ears
r
Dizziness
r
Facial weakness
r
Nasal obstruction
r
Nasal discharge
r
Facial pain
r
Headache
r
Nosebleed
Sneezing
“Stuffy” nose
Snoring
Loss of sense of smell
r
r
r
r
r
Growth in nose
r
Nasal bleeding
r
Drooling
r
Mouth growth/ulcer
Pronunciation
Chewing difficulty
Lump in neck
Dental problems/Poorly fitting
r
r
r
r
difficulty
dentures
r
Difficulty swallowing
r
Pain on
r
Heartburn
r
Breathing difficulty
swallowing
r
Bleeding from throat
r
Voice changes
r
Sore throat
r
N/A
Heart, Veins, Arteries (Cardiovascular):
Chest pain
Irregular Heart Beat
Dizziness
Swelling of legs
r
r
r
r
Leg pain with walking
Leg pain with rest
N/A
r
r
r
Lungs (Respiratory):
r
Wheezing
r
Cough
r
Shortness of breath
r
Mucous
r
Coughing up blood
r
N/A
Stomach, Intestines (Gastrointestinal):
Decrease in appetite
Nausea/vomiting
Blood in stool
Diarrhea/Constipation
r
r
r
r
r
Indigestion
r
Food intolerance
r
N/A
Bones, Joints, Muscles (Musculoskeletal):
r
Joint pain/Stiffness
r
Neck pain
r
N/A
Skin (Integumentary):
Rash
Jaundice
Recent baldness
N/A
r
r
r
r
Brain, Nerves (Neurological):
r
Headache
r
Blackout
r
Seizures
r
Paralysis
Tingling/Numbness
Tremor
N/A
r
r
r
Psychiatric:
r
Insomnia
r
Depression
r
N/A
Hormones (Endocrine):
Thyroid trouble
Heat or Cold
Excessive sweating
Excessive thirst
r
r
r
r
r
N/A
Intolerance
hunger, urination
Kidney, Bladder, Genitals (Genitourinary):
Painful urination
Difficulty passing urine
Blood in urine
Incontinence
r
r
r
r
Frequent urination
N/A
r
r
Blood (Hematologic/Lymphatic):
Bleeding problems
N/A
r
r
Physician Review with Patient:
Physician Signature
Date

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