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Name: _______________________ DOB: _________________ Today’s Date: ____________

Please place a check mark beside any of the following symptoms or problems if you have
experienced them recently or have concerns about them. If you don’t understand something,
place a question mark by it. Your doctor will discuss any positive responses with you.

A. General:                                         I. If you are a woman:
  Fevers, chills or sweat                               Unusual vaginal discharge
  Recent loss of appetite                               Loss of control of your urine
  Fatigue                                               Painful urination
  Recent unexpected weight loss                         Blood in urine
                                                        Increased frequency of urination
B. Eyes:                                                Have your periods stopped?
  Blurred or double vision                              Do you have excessive flow, pain, or other
  Eye pain or irritation                            menstrual symptoms that disrupt your life?
  Eye discharge                                         Genital sores
  Eye pain                                              Nipple discharge
  Failing vision                                        Breast mass or tenderness
  Sensitivity to light                                  Desires discussion on HIV
                                                        Desires Hormone Replacement Therapy
C. Ears, Nose, Throat                                   Desires Birth Control
  Earache
  Ringing in ears                                   J. If you are a man:
  Decreased hearing                                    Painful urination
  Difficulty swallowing                                Blood in urine
  Frequent nose bleeds                                 Increased frequency of urination
  Frequent sore throat                                 Urinating more than twice a night
  Prolonged hoarseness                                 Loss of control of your urine
  Sinus trouble or congestion                          Difficulty getting or maintaining an erection
                                                       Decreased desire for sexual intercourse
D. Cardiovascular:                                     Desires discussion on HIV
  Chest pain
  Fainting spells                                   K. Musculoskeletal:
  Palpitation (fast, irregular heart)                 Back pain
  Shortness of breath with exertion                   Joint pain
  Swollen ankles                                      Swelling in joints
                                                      Muscle cramping
E. Respiratory:                                       Muscle weakness
  Chronic cough                                       Muscle stiffness
  Chronic shortness of breath                         Arthritis
  Chronic wheezing
  Coughing up blood
  Excessive phlegm
F. Gastrointestinal:                                L. Psychological:
   Persistent nausea/vomiting                          Feeling depressed, sad
   Diarrhea                                            Memory loss
   Constipation                                        Difficulty concentrating
   Change in appearance of stool                       Phobias/unexplained fears
   Chronic abdominal pain                              No pleasure in life anymore
   Bloody or very black stool
   Jaundice (yellow skin)                           M. Endocrine:
                                                      Cold or heat intolerance
G. Skin:                                              Excessive appetite
  Skin rashes                                         Excessive thirst and urination
  Itching                                             Significant weight change
  Chronic dry skin
  Suspicious moles or other skin abnormalities      N. Heme/Lymphatic:
you are concerned about                               Excessive bruising or bleeding
                                                      Swollen glands in neck, armpits, or groin
H. Neurologic:
  Headache                                          O. Allergic/Immunologic:
  Unable to move parts of your body at times          Hives
  Weakness                                            Hay fever
  Numbness/tingling sensations                        Getting lots of infections
  Seizures/convulsions
  Fainting spells                                   P. Anything else you want your doctor
  Tremor/hands shaking                              to be aware of?
  Dizziness/vertigo


                                                                                       ...

                                                                                       ...

                                                                                       ...




                  Please print this form, fill it to the best of your knowledge.
                Fax it to 832-201-7711 or email it to admin@vedic-healing.com

                                   www.vedic-healing.com

                    “Turning Ancient Wisdom into Personalized Wellness”

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Review of Systems Form

  • 1. Name: _______________________ DOB: _________________ Today’s Date: ____________ Please place a check mark beside any of the following symptoms or problems if you have experienced them recently or have concerns about them. If you don’t understand something, place a question mark by it. Your doctor will discuss any positive responses with you. A. General: I. If you are a woman: Fevers, chills or sweat Unusual vaginal discharge Recent loss of appetite Loss of control of your urine Fatigue Painful urination Recent unexpected weight loss Blood in urine Increased frequency of urination B. Eyes: Have your periods stopped? Blurred or double vision Do you have excessive flow, pain, or other Eye pain or irritation menstrual symptoms that disrupt your life? Eye discharge Genital sores Eye pain Nipple discharge Failing vision Breast mass or tenderness Sensitivity to light Desires discussion on HIV Desires Hormone Replacement Therapy C. Ears, Nose, Throat Desires Birth Control Earache Ringing in ears J. If you are a man: Decreased hearing Painful urination Difficulty swallowing Blood in urine Frequent nose bleeds Increased frequency of urination Frequent sore throat Urinating more than twice a night Prolonged hoarseness Loss of control of your urine Sinus trouble or congestion Difficulty getting or maintaining an erection Decreased desire for sexual intercourse D. Cardiovascular: Desires discussion on HIV Chest pain Fainting spells K. Musculoskeletal: Palpitation (fast, irregular heart) Back pain Shortness of breath with exertion Joint pain Swollen ankles Swelling in joints Muscle cramping E. Respiratory: Muscle weakness Chronic cough Muscle stiffness Chronic shortness of breath Arthritis Chronic wheezing Coughing up blood Excessive phlegm
  • 2. F. Gastrointestinal: L. Psychological: Persistent nausea/vomiting Feeling depressed, sad Diarrhea Memory loss Constipation Difficulty concentrating Change in appearance of stool Phobias/unexplained fears Chronic abdominal pain No pleasure in life anymore Bloody or very black stool Jaundice (yellow skin) M. Endocrine: Cold or heat intolerance G. Skin: Excessive appetite Skin rashes Excessive thirst and urination Itching Significant weight change Chronic dry skin Suspicious moles or other skin abnormalities N. Heme/Lymphatic: you are concerned about Excessive bruising or bleeding Swollen glands in neck, armpits, or groin H. Neurologic: Headache O. Allergic/Immunologic: Unable to move parts of your body at times Hives Weakness Hay fever Numbness/tingling sensations Getting lots of infections Seizures/convulsions Fainting spells P. Anything else you want your doctor Tremor/hands shaking to be aware of? Dizziness/vertigo ... ... ... Please print this form, fill it to the best of your knowledge. Fax it to 832-201-7711 or email it to admin@vedic-healing.com www.vedic-healing.com “Turning Ancient Wisdom into Personalized Wellness”