REVIEW OF SYSTEMS



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or print it on a COLOR printer if you are filling it out prior to coming into the office.

|Review of Systems |

|Name:       |

|Date of Birth:       |Date:       |

| Yes No | Yes No |

|Skin |Genitourinary |

|Rashes |Difficulty with urination |

|Other conditions |Blood in urine |

| | |

|Head/Ears/Nose/Throat |Neurological |

|Headaches |Fainting |

|Vision problems/loss |Seizures |

|Hearing problems/loss |Memory loss |

|Nose/sinus problems | |

|Sore throat |Peripheral Vascular |

|Difficulty swallowing |Lower leg pain |

| |Calf pain |

|Respiratory |Loss of sensation |

|Cough |(Numbness or tingling in |

|Difficulty in breathing |hands or feet) |

| |Ankle swelling |

|Heart | |

|Shortness of Breath |Bleeding disorders |

|Chest pain | |

|Palpitations |Musculoskeletal |

| |Any joint pain or problems |

|Gastrointestinal |(Other than joint being treated |

|Appetite changes |at today’s visit) |

|Nausea/Vomiting | |

|Diarrhea |Current weight:       |

|Constipation | |

|Abdominal pain |Height:       |

|Gall bladder disease | |

| |Body Mass Index:       |

| |(Office to complete) |

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