REVIEW OF SYSTEMS

Patient First Name

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Patient Last Name

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Are you currently or have you had problems with your:

Cardiovascular (Blood Pressure, Chest Pain)

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If yes, please explain:

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Arthritis (Rheumatoid, Osteosarthritis):

Please select an option.

If yes, please explain:

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Neurologic (Numbness, Tingling, Balance):

Please select an option.

If yes, please explain:

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Constitutional (Weight Loss, Diet, Development):

Please select an option.

If yes, please explain:

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Stomach Ulcers:

Please select an option.

If yes, please explain:

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Diabetes:

Please select an option.

If yes, please explain:

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Liver Disease:

Please select an option.

If yes, please explain:

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Blood Clots:

Please select an option.

If yes, please explain:

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Disabled:

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If yes, please explain how and when:

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PAST MEDICAL HISTORY

Please indicate any major surgeries / hospitalizations / major injuries, the year they occurred and if there were any complications:

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Have you ever had general anesthesia (put to sleep)?

Yes

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If yes, were there any problems?

Yes

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If yes, please explain the problem:

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FAMILY MEDICAL HISTORY

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Do you have children?

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Do you live with:

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Do you exercise?

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If yes, what type or kind?

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Are you on any kind of special diet?

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If yes, what type or kind?

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Have you had a history of substance abuse?

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If yes, please explain:

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Do you smoke?

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If yes, how long have you smoked?

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How many packs per day?

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Do you drink alcohol?

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If yes, how much?

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How long?

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Education

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