New Patient Health Questionnaire Form Page 4
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4TEXAS CARDIOVASCULAR SPECIALISTS
REVIEW OF SYSTEMS QUESTIONNAIRE
(Please Circle)
Cardiac:
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Chest Pain
Palpitations
Sensation of skipping, pounding, racing heart
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Fainting or Near-Fainting
Leg swelling
Constitut:
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Unexplained weight gain
Weight loss
Weakness
Fatigue
EENT:
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Vision Changes
Blurred Vision
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Hearing loss
Ringing in the ears
Nosebleed
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Respiratory:
Non-productive cough
Productive cough
Blood in sputum
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Shortness of breath on exertion
Lying down
During sleep
Gastro:
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Appetite change
Nausea
Vomiting
Diarrhea
Constipation
Reflux
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Blood in stool
Black tarry stool
Urology:
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Blood in urine
Frequent urination
Poor bladder control
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Musculoskeletal:
Back pain
Joint pain
Muscle pain or cramping
Difficulty walking
Integumentary:
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Change in hair or nails
Discoloration
Rash
Neurological:
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Confusion
Dizziness
Headache
Memory changes
Numbness
Psychiatric:
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Anxiety
Depression
Hallucinations
Endocrine:
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Heat
cold intolerance
Skin changes
Hematologic:
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Bleeding
Excessive bruising
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Parent category: Life