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REVIEW OF SYSTEMS

PLEASE CIRCLE ANY CHANGES IN CONDITION OR SYMPTOMS YOU ARE CURRENTLY EXPERIENCING.

GENERAL: CHANGES IN ACTIVITY / ENERGY LEVEL, UNUSUAL WEIGHT GAIN/LOSS.

EYES:

CATARACTS, DROOPING EYELIDS, GLAUCOMA, VISION CORRECTION (GLASSES / CONTACTS), DIFFICULTY WITH VISION (BLURRED / DOUBLE).

EARS/NOSE/MOUTH/THROAT: CHANGES IN HEARING, HEARING LOSS, RECENT INFECTIONS, RINGING IN EARS, VERTIGO / DIZZINESS, SINUS BLOCKAGE, SNORING, SORES IN MOUTH, DENTURES, MOUTH PAIN, TONGUE PAIN.

RESPIRATORY: ASTHMA, COUGH, PNEUMONIA, RECENT RESPIRATORY INFECTION, SHORTNESS OF BREATH, PRODUCTIVE COUGH, TUBERCULOSIS, WHEEZING.

CARDIAC: CHEST DISCOMFORT, COLD HANDS OR FEET, DISCOLORATION OF HANDS OR FEET, SWELLING OF THE EXTREMITIES, HEART MURMURS, HIGH BLOOD PRESSURE, PALPITATIONS

GASTROINTESTINAL: ABDOMINAL PAIN OR SWELLING, CONSTIPATION DIARRHEA, CHANGES IN BOWEL HABITS, HEARTBURN, HEMORRHOIDS, NAUSEA, VOMITING, PAIN OR DIFFICULTY SWALLOWING.

GENITOURINARY: PROSTATE PROBLEMS, SEXUALLY TRANSMITTED DISEASE, SEXUAL DYSFUNCTION, CHANGES IN URINE: VOLUME, COLOR, ODOR, INCONTINENCE, FREQUENCY, RECENT INFECTIONS, KIDNEY STONES.

NEUROLOGICAL: PROBLEMS WALKING, LOSS OF BALANCE, BLACKOUTS, BURNING SENSATIONS, CHANGES IN CONCENTRATION, CONFUSION / DISORIENTATION, CONVULSIONS, LACK OF COORDINATION, EXCESSIVE DROWSINESS, EPISODES OR DIZZINESS, FAINTING, HEADACHES, LIGHTHEADEDNESS, LOSS OF CONSCIOUSNESS, LOSS OF SENSATION, MEMORY LOSS, NUMBNESS, SEIZURES, SPEECH DIFFICULTIES, STARING SPELLS, TINGLING SENSATIONS, DECREASED TOUCH SENSATION, TIA, TREMORS, COMPLAINTS OF WEAKNESS.

SKIN / BREAST / CHEST: BREAST LUMP NOTED, CHANGES IN SKIN COLOR OR YELLOWING OF THE SKIN, RASH, SKIN PAIN / ITCHING / DISCOMFORT.

PSYCHIATRIC: PERSONALITY CHANGES, COMPULSIVE BEHAVIOR, DEPRESSION, IRRITABLE, HOSTILE, NERVOUS, RESTLESS, MOOD SWINGS, SLEEP DISTURBANCES, INCREASED STRESS, TENSION, UNUSUAL BEHAVIOR.

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