David Schechter, M.D.

Review of Systems Form, New Patients

Name _____________________ , _______________ ___________Date ____________________

Last First Middle Month Day Year

Chief concern/reason for visit: ______________________________ When began? _________________

Other major concerns: _____________________________________________________________

Other symptoms or areas of your body that are bothering you: (please circle)

NEURO: headache––convulsions––seizures––fainting––A.D.D.––stroke__ NONE

Other:

PSYCHIATRIC: depression––anxiety––stress/excess worry––drug/alcohol issues NONE

Other:

EYES: Visual problem––Blurry Vision––Red Eyes NONE

Other:

NOSE: nasal allergies––nose bleeds NONE

Other:

THROAT: swallowing difficulty––frequent sore throats––speech problems NONE

Other:

MOUTH: dental problems––tongue problems––canker sores NONE

Other:

NECK: swollen glands––thyroid problems NONE

Other:

CHEST: chest pain––asthma––shortness of breath––cough––TB NONE

Other:

HEART: murmurs––palpitations––valve problems––mitral valve prolapse––angina NONE

Other:

INTESTINAL: colitis––ulcer gastritis––Barrett’s esophagus––polyps––constipation NONE

Other:

URINARY: urinary problems––urinary frequency––burning––kidney stones NONE

Other:

GENITAL: infection––warts––herpes––impotence––sexual difficulty NONE

Other:

UPPER EXTREMITY: NONE

pain in arm–– Carpal Tunnel––shoulder pain––elbow pain––wrist pain

Other:

LOWER EXTREMITY NONE

pain in legs––knee pain––hip pain––ankle pain––tingling

Other:

SPINE: low back pain––neck pain––mid back pain––scoliosis––herniated disc––sciatica NONE

Other:

SYSTEMIC: weight loss––fever––night sweats––trouble sleeping––loss of energy––arthritis NONE

Other:

I smoke: _____________ per day I drink ________________ alcohol per week

ALLERGIES TO MEDICATIONS: (State drugs and their reactions) NONE

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SURGERIES: (list type of surgery, year performed or your age at the time of surgery) NONE

MEDICATIONS OR SUPPLEMENTS YOU TAKE REGULARLY (include dosage if you recall) NONE

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