Home - Kitsap OBGYN
ID________________ MD_________OB__________ GYN_________ REVIEW OF SYSTEMS PATIENT QUESTIONNAIRE(Mark any that apply)Completed by: __________________________ Date:_______________ Reason for visit: _________________________Reviewed by: ___________________________Date: _______________General □ Fevers□ Chills □ Sweats □ Fatigue□ Weight lossEyes □ Blurring□ Vision lossEars/Nose/Throat□ Decreased hearing□ Nosebleeds □ Sore throat Cardiovascular □ Chest pain□ Palpitations□ Fainting □ Lower extremity swelling Respiratory □ Cough□ Wheezing □ Shortness of breathGastrointestinal □ Nausea/Vomiting□ Diarrhea □ Constipation □ Change in bowel habits □ Abdominal pain □ Blood in stool □ Stool incontinence □ BloatingGenitourinary□ Vaginal discharge□ Urinary Incontinence □ Painful urination □ Blood in urine □ Urinary frequency □ Missed periods □ Heavy Periods □ Bleeding after intercourse □ Pelvic pain □ Exposure to sexually transmitted infection □ Vaginal itching/irritation □ Vaginal dryness □ Vaginal odor □ Loss of interest in sex □ Pain with sexBreast□ Breast pain or tenderness □ Breast lump or mass □ Breast discharge Musculoskeletal □ Back or Joint Pain □ Joint swelling □ Muscle cramps □ Muscle weakness/stiffness Integumentary (Skin) □ Rash□ Itching □ Dryness □ Lesions □ Hair lossNeurologic □ Weakness□ Seizures□ Tremors □ Dizziness □ Headaches □ Numbness or tingling in hands/feet □ Memory lossPsychiatric □ Depression□ Anxiety□ Suicidal thoughts □ Hallucinations □ ParanoiaEndocrine □ Cold/heat intolerance □ Excessive thirst □ Excessive hunger □ Weight gain □ Hot flashesHemo/Lymphatic □ Abnormal bruising □ Bleeding w/cuts □ Enlarged lymph nodesAllergic/Immunologic □ Hives □ Hay fever □ Persistent infections □ HIV exposure ................
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