Please list any surgeries and/or hospitalizations:
Do you have ?
Living WillDNRPower of Attorney
If yes, please provide a copy
Review of Systems (please check box if you experience this symptom):
Constitutional:
FatigueFeverNight SweatsWeight LossWeight Gain
Cardiac:
Chest PainPalpitationsLeg Swelling
Renal:
Pain/Burning during UrinatingFrequent Urination
Eyes:
Need for GlassesBlurred VisionDouble VisionLoss of Vision
Sleep-Related:
SnoringSleepy During DayRestless SleepDifficulty Sleeping
Endocrine:
ThirstHeat/Cold Intolerance
Skin & Breast:
Skin LesionsRashesBreast MassesDischarge
Pulmonary:
Shortness of BreathWheezingCough
Psychiatric:
DepressionAnxiety
Musculoskeletal:
Back ProblemsJoint SwellingJoint Pain
Ear, Nose & Throat:
Sore ThroatEar RingingDecreased HearingDental ProblemsOral LesionsDifficulty SwallowingHoarseness
Neurological:
DizzinessLethargyPassing OutWeaknessDifficulty Speaking
Gastrointestinal:
HeartburnDiarrheaConstipationBlood in StoolHemorrhoidsLoss of Appetite
Family History: Have any members of your family ever had the following? (Please check)