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Silicon Valley Brain Imaging,
Inc. MEDICAL REVIEW OF SYSTEMS Please make a checkmark by any problem areas: |
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GENERAL Poor appetite Being overweight Recent weight gain or weight loss Hot or cold spells Abnormal sensitivity to cold or heat Difficulty sleeping Low resistance to infections Sweating excessively Urinating excessively Excessive thirst Other_______________________ NEUROLOGICAL Weak muscles Pacing due to muscle restlessness Forgotten periods of time Dizziness Drowsiness Muscle spasms or tremors Numbness Convulsions, fits Slurred.speech Other_______________________ RESPIRATORY Persistent cough Asthma, wheezing Repeated nose or chest colds. Coughing up blood or sputum Shortness of breath Rapid breathing Other_______________________ CHEST AND CARDIOVASCULAR Ankle swelling Rapid or irregular pulse Breast tenderness Chest pain High blood pressure Low blood pressure Other_______________________ MALES Itchy privates or genitals Impotence Painful or excessive urination Pus or blood in urine Abnormal Discharge Decreased Sexual Desire Pus or blood in urine Other_______________________ |
HEAD,
EYE, EAR, NOSE & THROAT Facial pain Frequent headaches Neck pain or stiffness Frequent sore throat Blurred vision Double vision Overly sensitive to light See spots or shadows Hearing loss in both ears Ear ringing Disturbances in smell Frequent runny nose Frequent dry mouth Sore tongue Other________________________ GASTROINTESTINAL AND HEPATIC Jaundice (yellowing of the skin) Trouble swallowing Frequent nausea or vomitting Frequent stomach aches or belly pain Painful bowel movements Frequent belching or gas Vomiting blood Rectal bleeding Other_________________________ MUSCULOSKELETAL Back pain or stiffness Bone or joint pain or stiffness Leg pain or muscle cramps Other_________________________ SKIN & HAIR Dry or itchy skin or scalp Easily bruises Excessive hair loss Sun sensitivity Other_________________________ FEMALES Menstrual irregularity or pain No menses Premenstrual moodiness, tension, bloating Painful intercourse Sterility or Infertility Painful or excessive urination Pus or blood in urine Other______________________ |