Systems Review: Please choose yes or no for the following:
RESPIRATORY
Pneumonia
--
Yes
No
Pleurisy
--
Yes
No
Shortness of breath
--
Yes
No
Cough
--
Yes
No
Spitting up blood
--
Yes
No
Chest pain
--
Yes
No
CARDIOVASCULAR
Murmur
--
Yes
No
High blood pressure
--
Yes
No
Palpitations
--
Yes
No
Heart Attack
--
Yes
No
If yes when?
GASTROINTESTINAL
Difficulty swallowing
--
Yes
No
Indigestion
--
Yes
No
Excess gas
--
Yes
No
Bloating after meals
--
Yes
No
Diarrhea
--
Yes
No
Nausea
--
Yes
No
Blood in stools
--
Yes
No
Ulcer
--
Yes
No
Hemorrhoids
--
Yes
No
Hepatitis
--
Yes
No
If yes, what type?
Liver disease
--
Yes
No
Jaundice
--
Yes
No
Heartburn
--
Yes
No
Gallbladder disease
--
Yes
No
Constipation
--
Yes
No
Vomiting
--
Yes
No
Black tarry stool
--
Yes
No
Abdominal pain
--
Yes
No
GENITOURINARY
Kidney infection
--
Yes
No
Kidney stone
--
Yes
No
Urinate at night
--
Yes
No
If yes, how often?
Blood in urine
--
Yes
No
Bladder infection
--
Yes
No
Are your periods regular?
--
Yes
No
Age of menstruation
Last period
Number of pregnancies
SYSTEMIC
Weight Loss
If yes, how much?
How long?
--
Yes
No
Weight Gain
If yes, how much?
How long?
--
Yes
No
Anemia
--
Yes
No
Tiredness
--
Yes
No
Weakness
--
Yes
No
INTEGUMENTARY
Skin infection
--
Yes
No
Rash
--
Yes
No
Breast mass
--
Yes
No
Skin cancer
--
Yes
No
Dermatitis
--
Yes
No
Breast cancer
--
Yes
No
ENDOCRINE
Thyroid disease
--
Yes
No
Diabetes If yes, what type?
--
Yes
No
Thyroid cancer
--
Yes
No
Heat Cold Insensitivity
--
Yes
No
Explain
HEMATOLOGIC
Bleeding disorder
--
Yes
No
Lymphoma
--
Yes
No
Low blood count
--
Yes
No
Leukemia
--
Yes
No
Easy Bruising
--
Yes
No
Low Iron
--
Yes
No
ALLERGY/IMMUNOLOGY
Environmental Allergies
--
Yes
No
Immune Disorders
--
Yes
No
Lupus
--
Yes
No
Rheumatoid Arthritis
--
Yes
No
HIV infections
--
Yes
No
NEUROMUSCULAR
Rheumatism
--
Yes
No
Ruptured Disc
--
Yes
No
Back trouble
--
Yes
No
