Page 5 - Forms - New Patient Paperwork (Dec-2017)_Neat

REVIEW OF SYSTEMS (CONT.)
Circle all that apply if YOU have (or have ever had) any of the following. If yes, please explain.
Difficulty with Anesthesia YES NO
Heart Disease YES NO
Hepatitis YES NO
Herpes YES NO
Hypertension (high blood pressure) YES NO
Kidney/Renal Disease YES NO
Lupus YES NO
Malignant Hyperthermia YES NO
Migraine Headaches YES NO
Mitral Valve Prolapse YES NO
Paralysis YES NO
Psychiatric Care YES NO
Seizures YES NO
Shortness of Breath YES NO
Sleep Apnea YES NO
Sleep Paralysis YES NO
Stomach/Bowel Problems YES NO
Stroke YES NO
Thyroid YES NO
TMJ YES NO

WOMEN ONLY
If male, please cross-out the following section and proceed with signatures.

Age Periods Began
Total Number of Pregnancies
Total Number of Live Births Did this include any C-section deliveries?
Did you breast feed?
Breast Lumps/Discharge
Do you perform self, breast exams regularly?
Date of your last mammogram: Within normal limits?

I hereby certify that the above information is true and correct to the best of my knowledge.

________________________________________________________ ___________________
Patient or Parent/Guardian Signature Date

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