Patient Name:_________________________________ Date of Birth:_________Today’s Date:___________

Review of Symptoms
Please mark anything below that represents any significant symptoms you have been experiencing.
(Feel free to bring out more details about these symptoms at your visit).

Constitutional: Gastrointestinal: Musculoskeletal:

___ Fevers (Temp >100.4F) ___ Abdominal Pain ___ Joint Pains
___ Chills ___ Nausea ___ Joint Deformities
___ Night Sweats ___ Vomiting ___ Muscle Aches
___ Fatigue ___ Diarrhea ___ Walking Difficulty
___ Loss of Appetite ___ Constipation ___ Frequent Falls
___ Weight Gain ___ Rectal Bleeding ___ None of the Above
___ Weight Loss ___ Heartburn Neurological:
___ None of the Above ___ Hemorrhoids ___ Numbness/Tingling
Eyes: ___ None of the Above ___ Muscle Weakness
___ Eye Discomfort or Pain Urinary: ___ Muscle Paralysis
___ Double Vision ___ Urge to Urinate ___ Slurred Speech
___ Blurred Vision ___ Frequent Urination ___ Seizures
___ Changes in Vision ___ Pain with Urination ___ Forgetfulness
___ Itchy Eyes ___ Night Time Urination ___ Difficulty Concentrating
___ Eye Drainage ___ Blood in Urine ___ None of the Above
___ None of the above ___ Incontinence of Urine Skin:
Ear, Nose & Throat: ___ Inability to Urinate ___ Rash
___ Ear Pain ___ None of the Above ___ Worrisome Moles
___ Decreased Hearing Genital (Male): ___ N/A ___ Changing Moles
___ Ear Drainage ___ Decreased Sex Drive ___ Skin Growths
___ Ringing in Ears ___ Erectile Dysfunction ___ Acne
___ Nasal Congestion ___ Genital Sores/Growths ___ Itchy Skin
___ Nose Bleeds ___ Pus from Penis ___ Dry Skin
___ Frequent Sneezing ___ Lump in Scrotum ___ None of the Above
___ Post Nasal Drip ___ Pain in Scrotum Psychiatry:
___ Sore Throat ___ None of the Above ___ Anxiousness
___ Trouble Swallowing Genital (Female):___ N/A ___ Depression
___ None of the Above ___ Decreased Sex Drive ___ Panic Attacks
Respiratory: ___ Painful Intercourse ___ Suicidal Thoughts
___ Cough ___ Vaginal Discharge ___ Homicidal Thoughts
___ Shortness of Breath ___ Vaginal Itching ___ Sleep Problems
___ Wheezing ___ Possible Pregnancy ___ Mood Swings
___ Mucous Production ___ Genital Sores/Growths ___ None of the Above
___ Coughing Blood ___ Irregular Bleeding Blood and Lymph System
___ None of the Above ___ Heavy Bleeding ___ Frequent/Easy Bruising
Cardiovascular: ___ Missed Periods ___ Bleeding Too Much
___ Chest Pain ___ Pelvic Pain ___ Forming Blood Clots
___ Chest Pressure ___ Significant PMS ___ Enlarged Lymph Nodes
___ Heart Palpitations --------------- ___ Painful Lymph Nodes
___ Swelling in Legs ___ Breast Lump ___ None of the Above
___ None of the Above ___ Breast Pain
___ Nipple Discharge
___ None of the Above

Physician Sign Off:_______________________________________________________________ Date:_____________