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? |
| | |
| | |
| | |
| |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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