Bay Area Heart
Important!
Call 911
if you are experiencing any symptoms of a heart attack.
(832) 905-5940
infobah@qoroshealth.com
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Important!
Call 911
if you are experiencing any symptoms of a heart attack.
Surgical Center
Patient Portal
Menu
Home
About Us
our providers
MEDICAL SERVICES
HOSPITALS AND INSURANCES
Patient Resources
Patient forms
Testing Instructions
PATIENT EDUCATION
Blog
Contact
REVIEW OF
SYSTEMS
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Name
*
Layout
General/Constitutional
Chills
Yes
No
Fever
Yes
No
Fatigue
Yes
No
Change in appetite
Yes
No
Weight loss
Yes
No
Weight gain
Yes
No
Lightheadedness
Yes
No
ENT
Dry mouth
Yes
No
Difficulty swallowing
Yes
No
Sore throat
Yes
No
Hematology
Easy bruising
Yes
No
Prolonged bleeding
Yes
No
Musculoskeletal
Leg cramps
Yes
No
Muscle aches
Yes
No
Joint stiffness
Yes
No
Peripheral Vascular
Decreased feeling in legs
Yes
No
Cold extremities
Yes
No
Cardiovascular
Chest pain at rest
Yes
No
Chest pain w exercise
Yes
No
Difficulty laying flat
Yes
No
Swelling of legs
Yes
No
Irregular heartbeat
Yes
No
Palpitations
Yes
No
Swelling in hands
Yes
No
Respiratory
Cough
Yes
No
Wheezing
Yes
No
Shortness of breath
Yes
No
Pain w deep breaths
Yes
No
General/Constitutional
Abdominal pain
Yes
No
Change in bowel habits
Yes
No
Constipation
Yes
No
Diarrhea
Yes
No
Heartburn
Yes
No
Nausea
Yes
No
Genitourinary
Difficulty urinating
Yes
No
Frequent urination
Yes
No
Painful urination
Yes
No
Neurologic
Dizziness
Yes
No
Headache
Yes
No
Memory loss
Yes
No
Low back pain
Yes
No
Tingling/Numbness
Yes
No
Psychiatric
Anxiety
Yes
No
Depressed mood
Yes
No
Submit
