Review of Systems Please answer every question. Choose Yes if it applies to you and No if it does not. Add details where requested. Leave this blank Patient information Patient full name Date of birth Phone number (optional) Constitutional Activity Change Yes No Appetite Change Yes No Chills Yes No Fatigue Yes No Fever Yes No Unexpected weight change Yes No Weight Gain Yes No Weight Loss Yes No History of COVID Yes No Eyes Eye Discharge Yes No Eye Itching Yes No Eye Pain Yes No Eye Redness Yes No Light Sensitivity Yes No Visual Disturbance Yes No Cataracts/macular degeneration/glaucoma Yes No Glasses/Contacts Yes No Do you see an Eye Doctor Yes No Eye doctor name (if Yes) Ears Ear Discharge Yes No Ear Pain Yes No Hearing Loss Yes No Tinnitus Yes No Hearing Aids Yes No Ringing in Ears? Yes No Nose/mouth/throat Congestion Yes No Dental Problem Yes No Mouth Sores Yes No Nose Bleeds Yes No Post Nasal Drip Yes No Rhinorrhea Yes No Sinus Pain Yes No Sore throat Yes No Trouble Swallowing Yes No Dentures Yes No Implants Yes No Runny Nose? Yes No Cardiovascular Chest Pain Yes No Leg Swelling Yes No Palpitations Yes No High Blood Pressure Yes No Taking medication for high BP Yes No High Cholesterol Yes No Taking any medication for high cholesterol Yes No Seeing cardiologist Yes No Irregular Heart Beat Yes No History of Heart Attack Yes No History of stents/bypass Yes No Respiratory Sleep Apnea Yes No CPAP/APAP/Dental device Yes No Chest tightness Yes No Cough Yes No Shortness of breath Yes No Wheezing Yes No Currently smoking Yes No History of smoking Yes No Second Hand Smoke Exposure Yes No COPD/Emphysema Yes No Inhalers Yes No Asthma Yes No Seeing Pulmonologist Yes No Gastrointestinal Distention Yes No Abdominal Pain Yes No Blood in stool Yes No Rectal Pain Yes No Constipation Yes No Diarrhea Yes No Nausea Yes No Vomiting Yes No Acid Reflux Yes No Are you taking medication for Acid Reflux? Yes No Acid reflux medications (if Yes) History of colon cancer? Yes No Family History of colon cancer? Yes No History of Colon Polyps? Yes No Family History of Colon Polyps? Yes No Genitourinary Difficulty urinating Yes No Painful Sexual Activity Yes No Painful Urination Yes No Leakage of Urination( Incontinence) Yes No Up at Night to Urinate Yes No Frequency of urination Yes No Genital Sore Yes No Blood in Urine Yes No Pelvic pain Yes No Urgency Yes No Erectile Dysfunction Yes No History of Enlarged Prostate Yes No Weak Stream Yes No Do you see a Kidney Specialist Yes No Kidney specialist name (if Yes) Do you see a Urologist? Yes No Urologist name (if Yes) Do you see a Gynecologist? Yes No Gynecologist name (if Yes) Musculoskeletal Joint Pain Yes No Back pain Yes No Walking problems Yes No Joint swelling Yes No Muscle Pains Yes No Neck pain Yes No Fibromyalgia Yes No Chronic pain Yes No Narcotics or Pain Pill Use Yes No Use a Walker Yes No Use a Cane Yes No Any Orthopedic Surgery? Yes No Orthopedic surgeries (if Yes) Do you see a Pain Speciliast? Yes No Pain specialist name (if Yes) Skin Color change Yes No Rash Yes No Wound Yes No Skin lesions Yes No History of Skin Cancer Yes No Family History of Skin Cancer? Yes No Do you see a Dermatologist? Yes No Dermatologist name (if Yes) Breast Breast Pain Yes No Breast lump Yes No Family History of breast Cancer Yes No Breast discharge Yes No Breast Implants Yes No History of Breast Cancer? Yes No Neurological Dizziness Yes No Headaches Yes No Migraines Yes No Numbness or Tingling Yes No Seizures Yes No Fainting Yes No Tremors Yes No Weakness Yes No History of TIA/stroke Yes No Neuropathy Yes No Any memory problems Yes No Psychiatric Depression Yes No Anxiety Yes No ADD Yes No Insomnia Yes No BiPolar Yes No Taking any medication for the Above Mental Health conditions? Yes No Is your medication working well? Yes No Decreased concentration Yes No Hallucinations Yes No Hyperactive Yes No Self injury Yes No Suicidal Ideas Yes No Alcoholism Yes No Alcohol daily use Yes No History of Drug Abuse Yes No Do you see a Psychiatrist or Mental Health Provider? Yes No Psychiatrist or mental health provider name (if Yes) Hematologic/lymphatic Swollen Glands/ Nodes Yes No Bruises Yes No Bleed easily Yes No Taking blood thinners Yes No Are you taking Aspirin Yes No Any Cancers Yes No Allergic/immunologic Environmental allergies Yes No Food Allergies Yes No Auto Immune Disorder Yes No Do you take Over the Counter Allergy Medications or Nasal Sprays? Yes No Allergy medications or nasal sprays (if Yes) Have you been tested for Allergys? Yes No Do you see an Allergist? Yes No Allergist name (if Yes) Are you on an Allergy Shot? Yes No Endocrine Low thyroid Yes No Taking medication for thyroid Yes No High thyroid Yes No Diabetes Yes No Taking medication for diabetes Yes No Prediabetes Yes No Osteopenia Yes No Osteoporosis Yes No Additional information (optional) I confirm my answers and agree to send this completed questionnaire as a PDF to insurance@thedoctorsoffice.net. Submit questionnaire Enable JavaScript to submit this questionnaire and keep your answers visible if an error occurs. We're Here Whenever You Need Us Emailinfo@thedoctorsoffice.net Phone(760) 631-4000 Open HoursMon - Fri: 8AM - 5PM Address161 Thunder Dr Ste 102, Vista, CA 92083. Quick Links Patient Portal About Contact Privacy Policy Telehealth Terms and Conditions Patient Consent and Acknowledgement Financial Policy
