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Review of Systems Are you currently experiencing any of these symptoms?

General Weight or appetite change Fatigue or weakness Fever or chills Excess sweating (diaphoresis) Neurologic Headache Numbness or tingling Dizziness or fainting Changes in memory Speech changes Tremor or seizure Psychiatric Trouble sleeping Changes in memory Nervousness Depression Stress Head and neck Head injury Neck pain Neck lumps Neck stiffness Ears Hearing changes Ringing in ears (tinnitus) Earache Drainage Eyes Vision changes Double vision (diplopia) Pain Redness Flashing lights Specks Nose Stuffiness Discharge Itching Nosebleeds Sinus pain Throat and mouth Bleeding Dryness Soreness Hoarseness Thrush Non-healing sores Skin Rashes Lumps Itching (pruritis) Dryness Color changes Hair and nail changes Hematologic Ease of bruising Ease of bleeding Breasts Lumps Pain Discharge Respiratory Cough (dry or wet, productive) Sputum (color?, amount?) Blood (hemoptysis) Shortness of breath (dyspnea) Wheezing Painful breathing Cardio/vascular Chest pain or tightness Palpitations SOB/dyspnea on exertion Difficulty breathing lying down (orthopnea) # pillows? Sudden awakening SOB (paroxysmal nocturnal dyspnea) Swelling in legs (edema) Walking calf pain (claudication) Leg cramping Gastrointestinal Swallowing diff. (dysphagia) Heartburn (reflux) Nausea or vomiting (describe!) Abdominal pain with meals bowel frequency/control Constipation Diarrhea Blood in stool (hematochezia) Black tarry stools (melena) Yellow eyes/skin (jaundice) Urinary Frequency/urgency/strength Burning or pain (dysuria) Blood in urine (hematuria) Loss of control (incontinence) Getting up at night (nocturia) Genital (male) Erectile dysfunction Pain with sex Hernia Penile discharge Sores Masses Genital (female) Itching or rash Pain with sex Vaginal dryness Hot flashes Musculoskeletal Gait difficulty Muscle or joint pain Stiffness or cramping Back pain Joint swelling or redness Endocrine Heat or cold intolerance Frequent urination (polyuria) Excess thirst (polydipsia) Excess hunger (polyphagia) Trauma/Injury?

Preventive health? Last eye exam Last dental exam Breast self-exam STD exam