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The Histories Family, Social, and Surgical histories forms are soon to come.

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patient
 
Male Female  

Single Married Widowed Divorced
 

 

 

REVIEW OF SYSTEMS

General

Weight loss or gain Fatigue Fever or chills
Weakness Trouble Sleeping

Skin

Rashes Lumps Itching
Dryness Color changes Hair and nail changes

Head

Headache Head injury

Ears

Decreased hearing Earache Drainage
Ringing in ears (tinnitus)

Eyes

Vision Glasses or contacts Pain
Redness Blurry or double vision Flashing lights
Specks Glaucoma Cataracts
Last eye exam

Nose

Stuffiness Discharge Itching
Hay fever Nosebleeds Sinus pain

Throat

Teeth Gums Bleeding
Dentures Sore tongue Dry mouth
Sore throat Hoarseness Thrush
Non-healing sores Last dental exam

Neck

Lumps Swollen glands Pain
Stiffness

Breasts

Lumps Pain Discharge
Self-exams Breast-feeding

Respiratory

Cough (dry or wet, productive) Sputum (color and amount) Coughing up blood (hemoptysis)
Shortness of breath (dyspnea) Wheezing Painful breathing

Cardiovascular

Chest pain or discomfort Tightness Palpitations
Shortness of breath with activity (dyspnea) Difficulty breathing lying down (orthopnea) Swelling
(edema)
Sudden awakening from sleep with shortness of breath
(Paroxysmal Nocturnal Dyspnea)

Gastrointestinal

Swallowing difficulties Heartburn Change in appetite
Nausea Change in bowel habits Rectal bleeding
Constipation Diarrhea Yellow eyes or skin (jaundice)

Urinary

Frequency Urgency Burning or pain
Blood in urine (hematuria) Incontinence Change in urinary strength

Genital

Male

Pain with sex Hernia STD’s
Penile discharge Sores Masses or pain
Erectile dysfunction

Female

Pain with sex Vaginal dryness Hot flashes
Vaginal discharge Itching or rash STD’s

Vascular

Calf pain with walking (Claudication) Leg cramping

Musculoskeletal

Muscle or joint pain Stiffness Back pain
Redness of joints Swelling of joints Trauma

Neurologic

Dizziness Fainting Seizures
Weakness Numbness Tingling
Tremor

Hematologic

Ease of bruising Ease of bleeding

Endocrine

Head or cold intolerance Sweating Frequent urination (polyuria)
Thirst (polydypsia) Change in appetite
(polyphagia)

Psychiatric

Nervousness Depression Memory loss
Stress

 

CERTIFICATION AND AUTHORIZATION
         
    * By checking the box on the left, I authorize the release of any medical information necessary to process the exchange of my clinical and non-clinical documents and/or to process my insurance claims.  
         
    * By checking the box on the left, I permit a copy of this authorization to be used in place of the original. This authorization may be revoked in writing by either me or my insurance company.  
         
    * By checking the box on the left, I have reviewed and understood all written office policies and billing policies of the clinic/hospital for which you are to provide these documents.  

 

 

 
 
 

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