Ear Specialty Center



Ear Specialty Center

REVIEW OF SYSTEMS

|Otology |Cardiovascular |Ophthalmologic |

| Hearing loss | Chest Pain | Blurring of vision |

|Right Left | | |

|Duration ____ ___ | | |

|Sudden in onset   | | |

|Progressive   | | |

|Hearing aid(s)   | | |

|How long? ____ ____ Current model| | |

|_______ _______ | | |

|Year purchased _______ _______ | | |

| | Palpations | Increased light sensitivity |

| | Shortness of Breath | Poor vision |

| | Swelling of ankles | Eye pain |

| |Respiratory |Endocrine |

| | Wheezing | Diabetes |

| | Difficulty breathing | Thyroid |

| | Cough | Hormonal imbalance |

| | Discolored phlegm | Irregular menstrual cycle |

| Difficulty with hearing: |Gastrointestinal |Dermatologic |

| In background noise | | |

| On telephone | | |

| With family | | |

| In social situations | | |

| Cafeteria | | |

| Work | | |

| | Nausea | Skin rash |

| | Heartburn | Psoriasis |

| | Constipation | Eczema |

| | Diarrhea | Skin Tumors |

| | Jaundice | Abnormal moles |

| | Bleeding | Identifiable scars |

| Tinnitus (Noise in head or Ears) |Genitourinary |Hematological |

| Causes insomnia | | |

| Bothers Concentration | | |

| Loss of work | | |

|Right Left | | |

| Ringing   | | |

| Buzzing   | | |

| Heart beat   | | |

| Duration ____ ____ | | |

| Frequency ____ ____ | | |

|(daily, occasionally, continuous) | | |

| | Burning on urination | Bruising |

| | Difficulty voiding | Excessive bleeding |

| | Bleeding in urine | Familial bleeding disorder |

| | Incontinence | Anemia |

| | Nocturnal urination | Frequent infections |

| |Neuropsychiatry |Musculoskeletal |

| | Seizures | Fractures |

| | Headaches | Back injury |

| | Migraines | Neck injury |

| | Numbness in extremities | Muscle tenderness |

| Dizziness | Back pain | Weakness |

| Spinning | | |

| Lightheadness | | |

| Giddy feeling | | |

| Causes Nausea | | |

| Causes Vomiting | | |

| Pressure in ear Right  Left | | |

| Associated with blurred vision | | |

| Frequency | | |

| Intermittent | | |

| continuous | | |

| Duration of Episodes | | |

| Seconds | | |

| Minutes | | |

| Hours to Days | | |

| Associate with headache | | |

| Associated with light sensitivity | | |

| Related to change of position | | |

| | Neck pain | Arthritis |

| | Memory loss | Skeletal deformities |

| |What questions would you like to ask? |

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| |What diagnostic tests (if any) have you recently completed? |

| | Hearing test Date of test? ________ |

| | Performed in family MD’s ofc. |

| | Performed in hearing aid dealer’s office |

| | Performed in ENT office. |

| | Electronystagmogram (ENG or dizziness test) |

| | MRI Scan |

| | CT Scan |

| | Blood tests |

| |

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