Surgical Services History Form (Page 2 of 2) in pdf

REVIEW OF SYSTEMS

Have you recently experienced any of the following (please check):

GENERAL/CONSTITUTIONAL:  Fever  Chills  Fatigue  Weakness  Weight gain  Weight loss None

HEENT: Eyes –  Pain Redness  Loss of vision  Double or blurred vision  Flashing lights or spots  Dryness

None

Ears, nose, mouth and throat – Ringing in the ears  Loss of hearing  Nosebleeds  Bleeding gums

 Sores in the mouth  Loss of sense of taste  Dry mouth  Food sticking in throat when swallowing

 Painful swallowing None

CARDIOVASCULAR:  Chest pain  Irregular heartbeats  Palpitation (heart races)  Shortness of breath

 Difficulty breathing at night  Swollen legs or feet None

RESPIRATORY: Coughing up blood  Coughing up mucus  Waking at night coughing

 Repeated pneumonias  Wheezing None

GASTROINTESTINAL: Change in appetite  Nausea  Vomiting  Vomiting blood or coffee ground material

 Heartburn  Yellow jaundice  Diarrhea  Constipation  Gas  Blood in the stools None

GENITOURINARY:  Difficult urination  Pain or burning with urination  Blood in the urine  Cloudy or smoky urine

 Frequent need to urinate  Urgency  Inability to hold urine  Kidney stones None

MUSCULOSKELETAL: Joint or muscle pain  Muscle weakness or tenderness  Joint swelling  Neck pain

 Back pain  Major orthopedic injuries None

SKIN AND BREASTS: Easy bruising  Skin redness, skin rash, hives  Sensitivity to sun exposure  Tightness, nodules

or bumps  Hair loss  Color changes in the hands or feet  Breast lump  Breast pain  Nipple discharge None

NEUROLOGIC:  Headache  Dizziness  Fainting  Loss of consciousness  Memory loss None

HEMATOLOGIC/LYMPHATIC:  Anemia  Bleeding tendency or clotting tendency None

I certify that the information that I have provided is accurate to the best of my knowledge.

__________________________________________________________________

__________________________

Patient signature

Date

__________________________________________________________________

__________________________

Interviewer signature

Date

FOR STAFF ONLY

IPV INFORMATION (for all clients)

 IPV card given Date: ____________________ Staff Signature: _____________________________

 If yes to IPV questions above, IPV acknowledged and safety resources provided.

*if in immediate danger, contact supervisor

NOTES: ____________________________________________________________________________________________________

__________________________________________________________________________ _____________________________

Clinician/Physician Signature

Date

Comments/Notes:

______________________________________________________________________________________________________________

Place Patient Label Here

AB108E – 3/15

Surgical Services History Form Page 2