Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Date_________ Name____________________________DOB_____________ Review of Systems New patient?--please mark all the symptoms that pertain to you currently and in the past. Repeat visit?—mark only the symptoms that you have experienced since your last visit. Mark all that apply-if no symptoms, mark none GENERAL (CONSTITUTION) appetite loss chills sweats (diaphoresis) fever general weakness fatigue/always tired 888(malaise) night sweats weight gain weight loss NONE of the above EARS/NOSE/THROAT (HENT) congestion ear discharge ear pain headaches hearing loss hoarseness nosebleeds painful swallowing 888(odynophagia) sore throat wheezing (stridor) ringing in ears 888(tinnitus) NONE of the above EYES blurred vision discharge double vision pain sensitivity to light 888(photophobia) redness vision loss-left eye vision loss-right eye visual disturbances visual halos NONE of the above CARDIOVASCULAR RESPIRATORY cough coughing up blood 888(hemoptysis) shortness of breath sleep disturbed due 888to breathing snoring sputum production wheezing NONE of the above changes in nail beds discoloration dryness flushing itching poor wound healing rash skin cancer suspicious lesions unusual hair 888distribution NONE of the above ENDOCRINE MUSCULOSKELETAL chest pain intolerance of cold pain in legs intolerance of heat 111(claudication)88 excessive thirst 888a(polydipsia) blueness around excessive hunger mouth or nailbeds (cyanosis) 88a8(polyphagia) shortness of breath excessive urination 888with exertion (dyspnea) ggg(polyuria) irregular heartbeats leg swelling near fainting NONE of the above aaaa(syncope) difficulty breathing 888while lying down HEME/LYMPH palpitations difficulty breathing aaaat night (PND) fainting (syncope) swelling of the lymph gggnodes (adenopathy) bleeding easy bruise/bleed 8aa8(orthopnea) NONE of the above SKIN NONE of the above arthritis back pain falls gout joint pain joint swelling muscle cramps muscle weakness muscle pain 888(myalgias) neck pain stiffness NONE of the above Review of Systems (continued) New patient?--please mark all the symptoms that pertain to you currently and in the past. Repeat visit?—mark only the symptoms that you have experienced since your last visit. Mark all that apply-if no symptoms, mark none GASTROINTESTINAL GENITOURINARY abdominal bloating abdominal pain appetite loss (anorexia) change in bowel 888habits bowel incontinence constipation diarrhea difficulty swallowing 888 (dysphagia) excessive appetite gas (flatus) heartburn/indigestion vomiting blood 888 888 (hematemesis) blood in stools 888 888 (hematochezia) hemorrhoids yellow skin color 888 888 (jaundice) dark tarry stools 888 888 (melena) nausea vomiting bladder incontinence decreased sex drive 888 (libido) painful or difficult aaaurination (dysuria) flank pain frequency genital sores blood in urine (hematuria) trouble starting urinary 888stream (hesitancy) incomplete emptying 888of bladder excessive heavy 888periods (menorrhagia) missed periods 888 888 (menses) excessive urination at 888night (nocturia) non-menstrual 888bleeding pelvic pain excessive urination 888 888 (polyuria) urgency NONE of the above NONE of the above 8.11.11 NEUROLOGIC PSYCHIATRIC trouble with altered mental 888speech (aphonia) 888status brief paralysis depression concentration hallucinations 888difficulty difficulty sleeping coordination 888 (insomnia) 888disturbed memory loss daytime sleepiness nervous/anxious dizziness substance abuse local weakness suicidal ideas light-headedness thoughts of loss of balance 888violence numbness NONE of the above numbing or 111(paresthesias) ALLERGY/IMMUNE seizures loss of feeling 888 gggg(sensory change) tremor sensation of room 888spinning (vertigo) environmental 888allergies HIV exposure hives persistent infection NONE of the above None of the above