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    Be Review of Systems Questionairet 122714

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    Djev David Daza
    This document is a review of systems questionnaire for a patient visit. It collects information on the patient's symptoms in various body systems over the last 7 days through checkboxes. It also collects information on the patient's chief complaint, medications, smoking status, pain level, safety concerns, and menstrual history. The form is signed by the patient and reviewed by a medical professional.

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    Download as PDF, TXT or read online from Scribd

    Be Review of Systems Questionairet 122714

    Uploaded by

    Djev David Daza
    52 views1 page
    This document is a review of systems questionnaire for a patient visit. It collects information on the patient's symptoms in various body systems over the last 7 days through checkboxes. It also collects information on the patient's chief complaint, medications, smoking status, pain level, safety concerns, and menstrual history. The form is signed by the patient and reviewed by a medical professional.

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    This document is a review of systems questionnaire for a patient visit. It collects information on the patient's symptoms in various body systems over the last 7 days through checkboxes. It also collects information on the patient's chief complaint, medications, smoking status, pain level, safety concerns, and menstrual history. The form is signed by the patient and reviewed by a medical professional.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    52 views1 page

    Be Review of Systems Questionairet 122714

    Uploaded by

    Djev David Daza
    This document is a review of systems questionnaire for a patient visit. It collects information on the patient's symptoms in various body systems over the last 7 days through checkboxes. It also collects information on the patient's chief complaint, medications, smoking status, pain level, safety concerns, and menstrual history. The form is signed by the patient and reviewed by a medical professional.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    REVIEW OF SYSTEMS QUESTIONNAIRE

    Patient Name: __________________________________________ Date of Birth: _________________

    What do you want to discuss most today? __________________________________________________

    Please circle any symptoms you have had in the last 7 days and explain answers.

    GENERAL CARDIOVASCULAR GASTROINTESTINAL


    Fatigue Yes Chest Pain Yes Abdominal Pain Yes
    Fevers Yes Palpitations Yes Constipation Yes
    Weight Loss Yes Bloody Stool Yes
    Weight Gain Yes SKIN Diarrhea Yes
    Insomnia Yes Rashes Yes Heartburn Yes
    Do you have a living will Yes Itching Yes Nausea/Vomiting Yes
    Do you smoke? Yes Mole Changes Yes
    Are you in pain 1-10? Yes GENITOURINARY
    MUSCULOSKELETAL (Changes in Bowel Habits)
    EYES, EARS, NOSE, & THROAT Joint Pain Yes Where? Painful urination Yes
    Visual Changes Yes Muscle pain Yes Where? Bloody urine Yes
    Hearing Loss Yes Leg Swelling Yes Where? Increased urination Yes
    Sore Throat Yes Leaking urine Yes
    Nasal Congestion Yes Do you wear pads? Yes
    NEUROLOGIC
    Ear Pain Yes Headaches Yes
    Dizziness Yes GYNECOLOGICAL
    NECK Difficulty Walking Yes Irregular Menses Yes
    Swollen Glands Yes Numbness or Tingling Yes Heavy menstrual cycles Yes
    Abnormal Vaginal Discharge Yes
    RESPIRATORY Pelvic Pain Yes
    PSYCHIATRIC
    Shortness of breath Yes Anxiety Yes
    Cough Yes Irritability Yes
    Wheezing Yes Suicidal Ideation Yes
    Depression Yes
    Concerns about your emotional or physical safety? Yes
    History of Domestic Violence/ Sexual Violence? Yes

    Any changes in medication since last visit? No Yes _____________________________________

    Patient Signature _______________________________________________ Date: ______________

    This form was reviewed by: _______________________________________ Date: ______________

    OFFICE USE ONLY

    Urine Pregnancy Test: Negative Positive Not Performed-Reason_______________________

    o Urine Pregnancy Test placed in computer o Medications Reconciled/ No active medications


    o Pharmacy Information placed in computer documented in Med Module

    o Height measured and placed in computer o Entire OB History pop up completed for NOB with Gs&Ps

    o Allergies entered o Health Maintenance updated

    o Status Chronic Conditions o Positive ROS documented


    o Appropriate vaccines prepared
    o Appropriate consents/forms prepared
    o Assess labs to be performed and add to careslip

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