System – Please check all that apply. General Negative Fever Fatigue Chills Sweats Bleeding problems Change in appetite Nutritional concerns Weight Loss Weight gain See comment Comment Head Negative Headaches HX of head injury/concussion See comment Comment Eyes Negative Impaired vision Pain Itching Dryness Redness Glaucoma Infection Double vision Corrective lenses/contacts See comment Comment Ears Negative Impaired hearing Deafness Discharge Pain Ringing in the ears Dizziness See comment Comment Nose and Sinuses Negative Diminshed sense of smell Bleeding Dryness Pain Discharge Obstruction Sinusitis Seasonal allergies See comment Comment Mouth and Throat Negative Sore throat Pain Infection Sore tongue Ulcers Blisters Lip lesions Canker sores Difficulty swallowing Hoarseness Tonsilitis Dental problems See comment Comment Neck Negative Stiffness Limited motion Pain Lumps Swollen glands See comment Comment Breasts Negative Discharge Bleeding Retraction Tenderness Size See comment Comment Skin Negative Rash Itching Color change Moles/changes Infection Hair/changes Nails/changes Tumors Sores Hives Lesion See comment Comment Respiratory Negative Cough Chest pain Wheezing Asthma Pneumonia Sputum (color/frequency) Recurrent infection Exposure to tuberculosis Cyanosis (Bluish tint to skin, lips, nails) Shortness of breath See comment Comment Cardiovascular Negative Chest pain Murmur Palpitations Difficulty Breathing Shortness of breath during exercise Fainting Phlebitis Varicose veins See comment Comment Hematologic / Lymphatic Negative Anemia Bleeding Malignancy Swollen lymph nodes Transfusion See comment Comment
Gastrointestinal Negative Nausea Vomiting Vomiting blood Diarrhea Heartburn Food intolerance Change in bowel habits Hernia Constipation Laxative or enema use Ulcers Abdominal pain Belching Black stools Stooling “accidents” Bloating Hemorrhoids See comment Comment Genitourinary Negative Burning Hesitancy Infection Urgency Blood in urine Incontinence Kidney stones Bedwetting Leakage Frequency Toilet trained See comment Comment Reproductive Negative Discharge Itching Infection Started menstrual cycle Painful menstrual cramps Contraceptive use Complication of pregnancy Sexually transmitted disease Childbirth Abortion Painful intercourse See comment Comment Musculoskeletal Negative Muscle cramps Pain Weakness Atrophy Swelling Joint pain Fractures Back Injury Curvature of spine See comment Comment Endocrine / Metabolic Negative Heat or cold intolerance Diabetes Hair/changes Excessive sweating Thirst Urinary frequency See comment Comment Neurologic Negative Headaches Fainting Seizures Dizziness Blindness Double vision Vision loss or change Paralysis Pain Numbness Tic Tingling Burning Poor coordination or balance Learning problems Attention problems Hyperactivity Developmental delay Unusual development/behavior Short attention span See comment Comment Psychiatric / Emotional Negative Sleep disturbances Unhappy, down or hopeless Suicidal expression or self-injurious behavior Severe mood swings Excessive worries or fears Fidgety, unable to sit still or trouble concentrating Does not play with others or has few friends Fights with other children Defiant or argumentative with adults Suspected drug or alcohol use Strange or nonsensical thinking or behavior Recent changes in family or school See comment Comment