Ob-Gyn Centre Of Excellence Patient Intake Form (Page 4 of 4) in pdf

Gastrointestinal

Neurological

REVIEW OF SYSTEMS

Loss of appetite ................................ 

Tingling or numbness....................... 

Please check all symptoms that apply:

Abdominal pain ................................ 

Seizures ............................................ 

Change in bowel movements ........... 

Frequent headaches .......................... 

Constitutional Symptoms

Nausea .............................................. 

Light headed or dizzy ....................... 

Good general health lately ................ 

Vomiting .......................................... 

Moodiness ........................................ 

Recent weight gain ........................... 

Diarrhea............................................ 

Recent weight loss ............................ 

Constipation ..................................... 

Fatigue .............................................. 

Musculoskeletal

Unable to restrain stools ................... 

Fever ................................................. 

Joint pain .......................................... 

Blood with bowel movement ........... 

Joint swelling ................................... 

Chills ................................................ 

Heartburn ......................................... 

Limitation of motion ........................ 

Polyps ............................................... 

Muscle cramps ................................. 

Eyes

Impaired vision (glasses/contacts).... 

Back pain ......................................... 

Peripheral vision changes ................. 

Urinary and Reproductive

Kidney stones ................................... 

Glaucoma ......................................... 

Endocrine

Urgency to urinate ............................ 

Cold intolerance ............................... 

Frequent urination ........................... 

Heat intolerance ............................... 

Ears/Nose/Throat

Leaking urine with sneezing ............ 

Chronic sinus problems .................... 

Diabetes ............................................ 

Blood in urine .................................. 

Nose bleeds ...................................... 

Excessive thirst or urination ............. 

Leaking urine with urgency ............. 

Skin dryness ..................................... 

Voice change or sore throat .............. 

Burning or painful urination ............ 

Thyroid Mass ................................... 

Possibility of pregnancy ................... 

Psychiatric

Post-coital bleeding .......................... 

Anxiety ............................................. 

Breast

Significant PMS ............................... 

Depression ........................................ 

Rash ................................................. 

Irregular periods ............................... 

Difficulty sleeping ........................... 

Itching .............................................. 

Heavy periods .................................. 

Excessive anger ................................ 

Tenderness ........................................ 

Painful periods ................................. 

Swelling ............................................ 

Memory loss or confusion ................ 

Painful intercourse ........................... 

Lumps ............................................... 

Nervousness ..................................... 

Pelvic pain ........................................ 

Moodiness ........................................ 

Nipple discharge ............................... 

Bloating ............................................ 

Suicidial or homicidal thoughts ....... 

Periods stopped ................................ 

Cardiovascular

Taking hormones ............................. 

Chest pain ......................................... 

Blood and Lymph

Hot flashes/night sweats................... 

Irregular heart beats .......................... 

Easy bleeding ................................... 

Lack of sexual desire........................ 

Easy bruising .................................... 

Shortness of breath walk/lying flat ... 

Postmenopausal bleeding ................. 

Slow to heal after cuts ...................... 

Rapid heart rate ................................ 

Unusual vaginal discharge ............... 

Anemia ............................................. 

Swelling of feet, ankles or hands ..... 

Vaginal dryness ................................ 

Varicose veins .................................. 

Blood clots ....................................... 

Hysterectomy ................................... 

Past transfusion ................................ 

Ovaries removed .............................. 

Enlarged glands/lymph nodes .......... 

Respiratory

Chronic or frequent coughs .............. 

Integument (Skin)

Rash.................................................. 

Coughing up blood ........................... 

Allergy

Itching .............................................. 

Shortness of breath ........................... 

Sinus allergy symptoms ................... 

Hair growth change .......................... 

Asthma or wheezing ......................... 

Frequent illness ................................ 

New skin lesions .............................. 

Allergic skin conditions ................... 

TB Exposure ..................................... 

Recent changes to skin ..................... 

Autoimmune problems ..................... 

Acne ................................................. 

Ob-Gyn Centre Of Excellence Patient Intake Form Page 4

Related Articles

Related forms

Related Categories