Review of Systems Template 3
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Name: _____________________________________

Today’s Date: __________________________

For new patients, established patients who may be having a new problem, or our patients who we
haven’t seen for a while, we need to update our records as to your general medical health. In each area,
if you are not having any difficulties, please check “No Problems.” If you are experiencing any of the
symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or explain any that may not be listed. If
you have any questions about this, please ask one of the technicians, or your doctor.
Const. (Health in General)
❑ No Problems Lack of energy, unexplained weight gain or
weight loss, loss of appetite, fever, night sweats, pain in jaws when eating, scalp tenderness, prior
diagnosis of cancer. Other: _______________________________________________________________
Ears, Nose, Mouth & Throat
❑ No Problems Difficulty with hearing, sinus problems, runny
nose, post-nasal drip, ringing in ears, mouth