New Patient History Form (Page 2 of 4) in pdf

Review of Systems: Circle all the symptoms listed below that you are CURRENTLY having.

General:

chills, fatigue, fever, night sweats, weight gain, weight loss

Allergy/Immunology:

immune deficiency, environmental allergies

Eyes:

blurry vision, eye pain

runny nose, congestion, difficulty swallowing, ear pain, ringing in ears,

Ears, Nose, Mouth:

sore throat

increased hunger, hair loss, cold intolerance, excessive thirst,

Endocrine:

heat intolerance

Respiratory:

shortness of breath, cough, wheezing, snoring

Breast:

breast lump, breast pain, nipple discharge, breast skin changes

Cardiovascular:

leg pain with walking, chest pain, fluid accumulation, palpitations

hernia, abdominal pain, blood in stools, constipation, diarrhea,

Gastrointestinal:

heartburn, nausea, vomiting

Hematology/Oncology:

frequent infections, easy bruising, easy bleeding

pelvic pain, menopause symptom, abnormal periods, genital sores,

Reproductive - Female:

vaginal discharge

Reproductive - Male:

erectile dysfunction, testicular pain, penile discharge, genital sores

Urinary:

blood in urine, difficulty urinating, kidney stones, bladder/kidney infections

Musculoskeletal:

recent trauma, muscle aches, joint pain, joint swelling

Skin:

discoloration, itching, rash, change in moles or spots

difficulty speaking, fainting, headache, loss of strength, memory loss,

Neurological:

tingling/numbness, tremor/shake

Psychological:

anxiety, depression, difficulty sleeping, physical or mental abuse

New Patient History Form Page 2