Review of Systems

 

YES   NO

___    ___   Loss of hearing

___    ___   Ringing in the ears

___    ___   Ear infection

___    ___   Bad vision

___    ___   Eye pain

___    ___   Eye infections

___    ___   Nose bleeds

___    ___   Sinus problems

___    ___   Sore throat

___    ___   Hoarseness

___    ___   Shortness of breath

___    ___   Back pain

___    ___   Rash

___    ___   Insomnia

___    ___   Memory loss

___    ___   Dizzy spells

___    ___   Palpitations

___    ___   Irregular pulse

___    ___   Swelling

___    ___   Feinting spells

___    ___   Chest pain

___    ___   Numbness

___    ___   Loss of appetite

___    ___   Indigestion

___    ___   Diarrhea

___    ___   Constipation

___    ___   Bloody or tarry stools

___    ___   Nervousness

___    ___   Depression

___    ___   Moodiness

___    ___   Phobias

___    ___   Hemorrhoids

___    ___   Blood in urine

___    ___   Frequent urination

___    ___   Hernia

___    ___   Sudden weight loss

___    ___   Fatigue

___    ___   Convulsions

___    ___   Headache

___    ___   Joint pain