Constitutional: fever, chills, weight loss, weight gain, weakness
EENT: vision loss, vision changes, pain, double vision, glasses, contacts, cataracts, glaucoma, last
eye exam, hearing changes, ringing in ears, dizziness, ear discharge, ear pain, nasal
congestion, running nose, sinus pain, sore throat, hoarseness, voice changes, mouth
sores, dentures, last dental visit
CV: chest pain, chest tightness, palpitations, shortness of breath, racing heart, high blood
Pressure, high cholesterol, heart attack, leg cramps
RESP: cough, sputum, coughing up blood, wheezing, shortness of breath, painful breathing
GI: difficulty swallowing, Heartburn, Indigestion, change ball habits, blood in stool, appetite
changes, nausea, Vomiting, Diarrhea, Constipation, last colonoscopy
GU: urinary frequency, urgency, Incontinence, burning or pain, blood and urine, vaginal or penile
discharge
MS: Stiffness, back pain, redness or swelling of joints, Injuries
NEURO: headache, Head injury, dizziness, seizures, tremors, tingling, numbness, memory loss,
balance problems, falls
INT: rashes, lumps, itching, hair or nail changes, changing moles, new moles
PSYC: depression, anxiety, stress, nervousness, excessive worry, diminished interest and
activities, feelings of hopelessness, Suicidal thoughts
ENDOCRINE: Heat or cold intolerance, sweating, unexplained weight loss, excessive hunger or
thirst, frequent urination
HEMATOLOGY: Easy bruising, excessive bruising, easy bleeding, anemia, blood disease,
cancer, blood transfusions