Arrant Surgical
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Review of Systems
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Review of Systems
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Name
*
First
Last
Constitutional Symptoms
Fever
Chills
Abnormal Weight Gain
Abnormal Weight Loss
Other/Description:
Eyes
Blurred Vision
Double Vision
Eye Pain
Other/Description:
Allergic/Immunologic
Hay Fever
Drug Allergies
Food Allergies
Other/Description:
Neurological
Seizures
Tremors
Dizzy Spells
Numbness
Tingling
Other/Description:
Genitourinary
Painful Urination
Urinary Frequency
Scant Urination
Frequent Urinary Tract Infections
Prostate Problems
Sexual Dysfunction
Urinary Incontinence (Leakage)
Other/Description:
Hematologic/Lymphatic
Swollen/Enlarged Lymph Nodes
Excessive Bleeding
Blood Clot History
Religious Objection to Blood Transfusion
Other/Description:
Digestive System
Heartburn
Diarrhea
Constipation
Food Intolerance
Nausea
Belching
Bloating
Digestive Pain
Other/Description:
Integumentary
Skin Rash
Easy Bruising
Nail Problems
Other/Description:
Musculoskeletal
Joint Pain
Joint Swelling
Back Pain
Difficulty Ambulating (Walking)
Other/Description:
Head/Ear/Nose/Throat/Mouth
Ear or Sinus Pain
Nasal Obstruction
Sore Throat
Hearing Loss
Headache
Other/Description:
Cardiovascular
Chest Pain
Palpitations/Irregular beats
Calf Pain or Heavy Legs
Other/Description:
Respiratory/Lungs
Wheezing
Frequent Coughs
Sputum
Asthma
Other/Description:
Breasts
Implants
Discharge
Fibrocystic Disease
Lumps
Breast Pain
Other/Description/Date of Last Mammo:
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