Coastal New Patient Encounter Form Page 3
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4REVIEW OF MEDICAL SYSTEMS:
(Check any of the following symptoms that you have or have experienced in the past few months.)
CONSTITUTIONAL:
EYES:
Significant Weight Loss
Blurry Vision
Significant Weight Gain
Corrected Vision
Difficulty Sleeping
Other: ______________
Unexplained High Fever
None.
Other: _____________
CARDIOVASCULAR:
None.
Chest Palpitations
EARS, NOSE & THROAT:
Chest Pain
Difficulty Hearing (Hearing Aid, etc.)
Other: ______________
Chronic Ear Infections
None.
Difficulty Smelling
HEMATOLOGY / ENDOCRINOLOGY:
Difficulty Swallowing
Easy Bruising
None / Other: _____________
Uncontrollable Bleeding
GASTROINTESTINAL:
Persistent Warmth / Coolness
Heartburn
Other: ______________
Diarrhea
None.
Constipation
ALLERGY / IMMUNOLOGY:
Persistent Abdominal Pain
Rash
None / Other: _____________
Itching
SKIN:
Persistent Sinus Infection
Discoloration of Skin
Other: ______________
Enlarging Mass
None.
Irregular Moles
NEUROLOGICAL:
Breast Lump
Numbness
Other: _____________
Tingling
None.
Persistent / Frequent Headaches
MUSCULOSKELETAL:
Other: ______________
Joint Pain
None.
Joint Stiffness
RESPIRATORY:
Swelling
Persistent Cough
Loss of Strength
Shortness of Breath
Other: _____________
Other: ______________
None.
None.
PSYCHOLOGICAL:
Significant Mood Changes
Memory Loss
Anxiety
Other: _____________
None.
UROLOGICAL:
Blood In Urine
Difficulty Starting Urine
Difficulty Maintaining Stream
Other: _____________
None.
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