YES CONSTITUTION NO YES EYES NO YES

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YES

CONSTITUTION NO Activity Change Appetite Change Chills Diaphoresis Fatigue Fever Unexpected weight change

HENT Facial swelling Neck pain neck stiffness Ear discharge Hearing Loss Ear Pain Tinnitus (Ringing) Nosebleeds Congestion Rhinorrhea (Nose) Postnasal drip Sneezing Sinus pressure Dental problem Drooling Mouth Sores Sore Throat Trouble swallowing Voice change

YES

EYES NO Eye discharge Eye itching Eye pain Photophobia (Light Sensative) Visual disturbances RESPIRATORY Apnea Chest tightness Choking Cough Shortness of breath Stridor (Vibrations) Wheezing CARDIOVASCULAR Chest pain Leg swelling Palpitations GI Abd distention Abdominal pain Anal bleeding Blood in stool Constipation Diarrhea Heartburn Nausea Rectal pain Vomiting

YES

ENDOCRINE NO Cold intolerance Heat Intolerance Polydipsia (Thirsty) Polyphagia (Hungry) Polyuria (Lots of urine) GU Difficulty urninating Dyspareunia (Intercourse pain) Dysuria (Urination pain) Enuresis (Involuntary urination) Flank pain Frequency Genital sore Hematuria (Blood in urine) Incontinence (Bladder) Menstrual problem Nocturia (Night Urination) Pelvic pain Urgency Urine decreased Vaginal bleeding Vaginal discharge Vaginal pain MUSC Arthralgias (Joint pain) Back pain Gait problem (Walking) Joint swelling Myalgias (Muscle pain) SKIN Color change Pallor (Pale color) Rash Wound

YES

ALLERG / IMMUNO NO Environmental allergies Food allergies Immunocompromised NEUROLOGICAL Dizziness Facial asymmety Headaches Light-headedness Numbness Seizures Speech difficulty Syncope Tremors Weakness HEMATOLOGIC Adenopathy (Inflammation of glands)

Bruises/bleeds easily PSYCHIATRIC Agitation Behavior problem Confusion Decreased concentration Dysphoric mood (Uneasy)

Hallucinations Hyperactive Nervous / anxious Self-injury Sleep disturbance Suicidal ideas