Download Pain or Burning with Urination

REVIEW OF SYSTEMS
Do you now or have you recently had problems with any of the following?
Please circle your answer.
Patient Name:
Pain or Burning with Urination
G / U SYSTEM:
Getting Up at Night to Urinate
Abnormal Vaginal Bleeding
Kidney Stone
Leaking of
Urine
Sexual
Problem
Frequency
Urgency
Blood in Urine
Poor Bladder
Emptying
Menstrual
Problems
Erectile Problems
Small or Slow Stream
Recurrent Urine
Infection
GENERAL:
Change in Weight
Fever
Night
Sweats
Poor Appetite
SKIN:
Lumps or Nodules
Breast Lump
Rashes
Sores
EYES:
Glaucoma
Cataracts
Glasses
Other Eye
Problems
ENT:
Trouble Swallowing
Nosebleeds
Dentures
Sinus Problems
Earaches
HEME / LYMPH:
Swollen Nodes or Glands
Blood Clots
Anemia
Bleeding Problems
Other Blood Disorders
Irregular Heart Beat
Heart Failure
Angina
Heart Murmur
Heart Valve Problem
Pain in Legs with Exertion
Chest Pain
Phlebitis
Swelling in Legs
Blood Clots
Shortness of Breath
Wheezing
Cough
Asthma
Other Lung Problems
Gall Bladder Problems
Blood in Stool
Diarrhea
Intestinal Bleeding
Dark Tarry Stools
Poor Appetite
Hiatal Hernia
Ulcer
Indigestion
Hemorrhoids
Constipation
Vomiting
Nausea
Hernia
NEURO:
Loss of Consciousness
Numbness
Headaches
Weakness
Strokes
Dizziness
PYSCH:
Bipolar Disorder
Anxiety
Depression
Insomnia
Joint Replacement Surgery
Joint Pain
Gout
Arthritis
Muscle Aches
Heat or Cold Intolerance
Hot Flashes
Flushing
Abnormal Thirst
Changes in Body Hair
Skin Pigmentation Changes
Fatigue
CARDIOVASCULAR:
Other Skin Problems
Other Heart / Blood Vessel
RESPIRATORY:
G / I:
MUSCOSKELETAL:
ENDROCRINE:
Paralysis
Broken Bones
Do you have any other problem you want to discuss with the doctor?
YES
NO
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PATIENT’S SIGNATURE
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DATE
PHYSICIAN’S SIGNATURE
DATE