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Welcome to Pulmonary Medicine of Dayton, Inc. We look forward to serving you. Kindly fill out - page 5 / 8

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Constitution:

Fever

Fatigue

Chills

Night Sweats

Cardiovascular:

Chest Pain

Palpitations

Swelling (edema)

Murmurs

Eyes:

Blurred Vision

Loss of Vision

Double Vision

Glaucoma

Ears, Nose, and Throat

Hearing Loss or Pain

Ringing in ears

Nasal Obstruction

Hoarseness or Sore Throat

Allergy/Immunology:

Runny Nose

Sneezing

Allergic reactions

Bloody Nose

Hematology/Lymph:

Easy Bruising

Bleeding Tendency

Enlarged Lymph Nodes

. Neurology:

Headaches

Seizures

Coordination Problems

Dizziness

Skin:

Rash

Itching

Dry Skin

Unusual Moles

Musculoskeletal:

Joint Pain

Joint Swelling

Weakness

Back Pain

Psychiatric:

Feeling Anxious

Feeling Depressed

Feeling Sad

Thinking of Suicide

Gastrointestinal:

Heartburn

Nausea Vomiting

Diarrhea! Constipation

Abdominal Pain

Endocrine:

Excessive Thirst

Excessive Urination

Heat Tolerance

Cold Intolerance

Genitourinary:

Frequent Urination

Loss of Bladder control

Difficult Urination

Painful urination

Breast Lumps

Skin Sores

Changes in Urine color

Watery Eyes

Bleeding Gums

Dentures

Hives

Localized Rash

Weight Loss

Weight Gain

.

Please circle any of the following that you have recently experienced.

Trouble Swallowing

Changes in Stool

Felipe A. Rubio, MD Hemant M. Shah, MD Mariano M. Iberico, MD Salman S. Razi, MD Median Ali, MD

Appointment Date:___________________ Name:_____________________________ DOB:__________________

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