ROS Constitutional Symptoms fever chills night sweats fatigue recent weight loss/gain Cardiovascular cold feet irregular or fast heartbeat pain in calves swelling in feet/ankles/hands Endocrine heat/cold intolerance excessive thirst or urination Ear,Nose,Mouth,Throat difficulty swallowing ear infections/drainage hearing loss or ringing hoarseness loss of balance nasal stuffiness neck pain/stiffness nosebleeds sore throat/tonsils swollen glands in neck Eyes blurred/double vision dry eyes wears glasses/contacts Gastrointestinal abdominal pain bloating blood in stool change in bowel pattern constipation frequent diarrhea gas heartburn loss of appetite nausea/vomiting rectal bleeding Genitourinary blood in urine burning or painful urination change in force/flow frequent urination Skin acne dermatitis hives irregular moles rash/itching ulcers warts Hematologic/Lymphatic slow to heal after cuts phlebitis/blood clots Males difficulty urinating penile discharge testicle pain testicular/scrotal mass Musculoskeletal/ Neuromuscular burning in feet/legs hip/knee/low back pain joint pain/stiffness muscle aches/cramps numbness feet/legs weakness of muscle/joints Neurological convulsions/seizures frequent recurring headaches light headed/dizzy numbness or tingling Psychiatric chemical dependency depression memory loss/confusion suicidal thoughts Respiratory asthma or wheezing cough phlegm shortness of breath snoring at night spitting up blood Females breast pain,mass or discharge heavy bleeding irregular period prolonged period severe menstrual pain vaginal discharge are you pregnant Date of last period MM slash DD slash YYYY Is there anything you wish to tell the physician privately? Yes No Patient Signature Date MM slash DD slash YYYY Physician Signature Date MM slash DD slash YYYY Δ
