Survey
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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Patient Review of Systems Name: _____________________ Date: _________________ DOB: _____________ Have you recently been bothered by any of the following? Check the box in front of the symptom or circle it. General: □ fever □chills □ sweats □ loss of appetite □ fatigue □ weakness □ tiredness □ weight loss □ sleep disturbance Eyes: □ vision loss □ seeing double □ irritation □ blurry vision □ eye pain □ seeing halos □ discharge □ light sensitivity Ears/Nose/Throat: □ ringing □ discharge □ earache □ decreased hearing □ nasal congestion □ nosebleeds □ difficulty swallowing □ hoarseness □ sore throat Cardiovascular: □ chest pain or discomfort □ racing/skipping heart beats □ fatigue □ lightheadedness □ dizziness (spinning) □ shortness of breath with exertion □ palpitations □ swelling of hands or feet □ difficulty breathing at night or while lying down □ fainting □ leg cramps with walking □ blue discoloration of lips or nails □ sudden weight gain Respiratory: □ cough □ shortness of breath □ coughing up blood □ chest discomfort □ wheezing □ excessive sputum □ excessive snoring □ fatigue after awakening GI (stomach and intestines): □ excessive appetite or thirst □ loss of appetite □ frequent indigestion □ vomiting blood □ nausea □ vomiting □ yellowish skin/eyes □ excessive gas □ abdominal pain □ abdominal bloating □ hemorrhoids □ diarrhea □ change in bowel habits □ constipation (hard stool) □ dark tar-like stools □ bloody BM’s or stools GU (genitor-urinary): □ foul smelling urine □ blood in urine or tea-colored urine □ frequent urination □ inability to empty bladder □ urgent urination □ kidney pain □ trouble starting urine stream □ pain with urination □ frequent night-time urination □ inability to control urination □ sores on your genitals Women: □ irregular periods □ heavy periods □ missed periods □ concern that you might be pregnant □abnormal vaginal bleeding or discharge □ painful intercourse □ pelvic pain □ history of abnormal Pap Smears Musculoskeletal: □ muscle cramps □ joint pain □ joint swelling □ joint fluid □ back pain □ stiffness □ muscle weakness □ arthritis □ gout □ loss of strength □ muscle aches Skin: □ excessive perspiration □ night sweats □ suspicious skin lesions □ changes in nails □ dry skin □ poor wound healing □ changes in hair □ skin cancer □ itching □ changes in skin color □ flushing □ rash Neurological: □ difficulty with concentration □ poor balance □ headaches □ disturbance in coordination □ numbness □ inability to speak or speech changes □ frequent falling □ tingling □ brief paralysis □ visual disturbance □ seizures □ weakness □ dizziness (spinning) □ tremors □ fainting □ excessive daytime sleepiness □ memory loss □ restless legs syndrome Psychiatric: □ anxiety □ feelings of panic □ feeling sad or blue frequently □ feeling hopeless □ thoughts of suicide □ sounds, voices, or sights that no one else hears or sees Endocrine (glandular): □ excessive hunger □ cold intolerance □ heat intolerance □ excessive urination □ excessive thirst □ recent weight changes Hematological (blood): □ enlarged lymph glands □ bleeding □ abnormal bruising □ frequent fevers □ frequent infections Allergy: □ frequent congestion □ frequent hives □ seasonal allergies □ severe food allergies □ history of severe reaction to bee or wasp sting Infectious disease: □ transfusion before 1991 □ tattoo under questionable hygiene standards □ history of sharing needles (for any purpose) or of high-risk sexual relations □ recent travel to region with an unusual disease outbreak □ recent tropical travel □ household member with TB or other infectious disease Further details if needed: