Christianacare.org
Christiana Care Neurology SpecialistsName___________________________________________________ Date____________________Please circle any conditions that may apply._____Check here if there have been no changes since your last visit LINK Excel.Sheet.12 "\\\\USCHR4\\801148793$\\My Documents\\ros.xlsx" Sheet1!R1C1:R30C1 \a \f 5 \h \* MERGEFORMAT ConstitutionalRespiratorySkinweight changesCoughRashes / lumps or soresfatigueCoughing Blood / HemoptysisBreast lumps or soresfeverAsthmaEmphysemaPsychiatricEyesTuberculosisHistory of psychiatric illnessDouble visionGlaucomaGastrointestinalEndocrineCataractsTrouble swallowingThyroid troubleVision LossNauseaHeat/cold intoleranceVomitingExcessive sweatingENTBloody stools / bleedingDiabetesRinging in ears / TinnitusBlack stoolsExcessive thirst or hungerDizziness / VertigoConstipationExcessive urinationHearing LossDiarrheaNose bleedAbdominal painHematologicSinus trouble Liver or gallbladder troubleAnemiaBleeding gumsHepatitisEasy bruising/bleedingHoarsenessPast transfusionsGenitourinarySwollen glandsCardiovascularFrequent urinationHeart troubleUp at night to urinateAllergic / ImmunologicHigh blood pressureblood in urine / HematuriaAutoimmune diseaseRheumatic feverUrgencyHeart MurmurHesitancyFemalesChest PainIncontinenceMenopausePalpitationsKidney stoneMenstrual problemsShortness of breath / DyspneaBurning/pain on urinationVaginal infectionPhlebitisPain in calves when walkingMusculoskeletalMalesMuscle or joint painHerniaArthritisAbnormal dischargeGoutTesticular pain ................
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