SYSTEMS REVIEW
Patient Information
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?