SYSTEMS REVIEW

Patient Name

Patient ID No.

Previous Hospitalizations or Surgeries (including dates)

Did you have problems with surgery?
No
Yes

Problems with anesthesia?
No
Yes

Have you been diagnosed with:

Heart Disease
No
Yes

High/Low Cholesterol
No
Yes

Diabetes
No
Yes

Snoring
No
Yes

Depression/Other Mental Illness
No
Yes

High Blood Pressure
No
Yes

Asthma
No
Yes

Reflux
No
Yes

Eczema/Psoriasis
No
Yes

Other

Please check all problems and conditions which apply to you

EYES
Vision changes
Glasses/Contacts
Cataracts
Glaucoma

EAR, NOSE, MOUTH and THROAT
Nose bleeds
Dizzy Spells
Congestion
Frequent sore throats
Hearing loss
Snoring
Daytime sleepiness

RESPIRATORY
Asthma
TB
Shortess of breath
Chronic cough

CARDIOVASCULAR
Chest pain/tightness/pressure
High blood pressure
Heart attack
Stroke
Poor circulation

GASTROINTESTINAL
Hepatitis
Ulcers
Heartburn
Digestive problems
Hemorrhoids
Blood in stool
Constipation
Diarrhea

GENITO-URINARY
Kidney problems
Frequent urinary tract infections
Menstrual problems

SKIN
Eczema
Psoriasis
Skin cancer

MUSCULOSKELETAL
Joint pain
Swelling in joints
Arthritis

NEUROLOGIC
Headaches
Dizziness
Seizures
Memory loss

ENDOCRINE
Diabetes
Hypothyroid
Hyperthyroid

ALLERGY
Hay fever
Food allergies

GENERAL
Depression
Fatigue
Cancer – what type?