E&M Appointment Preparation

Chief Concern *This question is required.This is the one issue or concern that is the main focus for your visit. A short sentence or phrase is fine. For example - "I am feeling more depressed." or "I have started to have headaches."

• I am concerned about depression.
• I am concerned about anxiety.
• I am concerned about mood swings.

• I am concerned about a medication side effect.
• I have another concern, describe below. Please enter an 'other' value for this selection. * This question is required.

Comments

ROS: GeneralCheck any of these symptoms that you have had since our last visit.

• fever
• unexplained falls
• change of appetite
• itch
• recent injury

• unexplained weight loss
• fatigue
• rash
• night sweats
• lethargy

ROS: EyesCheck any of these symptoms that you have had since our last visit.

• visual changes
• eye pain
• double vision

• blind spots
• floaters

ROS: Ear, Nose and ThroatCheck any of these symptoms that you have had since our last visit.

• runny nose
• frequent nose bleeds
• sinus pain
• stuffy ears
• ear pain

• ringing in ears (tinnitus)
• gum bleeding
• toothache
• sore throat

ROS: CardiovascularCheck any of these symptoms that you have had since our last visit.

• chest pain
• shortness of breath
• swelling in your ankles (edema)

• palpitations
• faintness
• loss of consciousness

ROS: RespiratoryCheck any of these symptoms that you have had since our last visit.

• cough
• wheezing

• coughing up blood
• exercise intolerance

ROS: GastrointestinalCheck any of these symptoms that you have had since our last visit.

• abdominal pain
• difficulty swallowing
• indigestion
• bloating

• cramping
• nausea/vomiting
• diarrhea/constipation
• vomiting blood

ROS: GenitourinaryCheck any of these symptoms that you have had since our last visit.

• urinating without making it to the bathroom
• pain when urinating
• blood in urine
• urinating at night
• increased urination

• trouble starting a urine stream
• vaginal discharge or pain
• change in menstrual pattern
• painful menstruation

ROS: MusculoskeletalCheck any of these symptoms that you have had since our last visit.

• pain in arms or legs
• stiffness in joints

• joint swelling
• decreased range of motion

ROS: SkinCheck any of these symptoms that you have had since our last visit.

• itching skin
• rashes
• skin wounds

• excessive dryness of the skin
• discoloration of the skin

ROS: NeurologicalCheck any of these symptoms that you have had since our last visit.

• changes in sight, smell, hearing and taste
• seizures
• fainting
• headache

• pins and needles (tingling) or numbness or weakness in limbs
• poor balance
• trouble speaking clearly

ROS: PsychiatricCheck any of these symptoms that you have had since our last visit.

• depression
• thoughts of suicide
• substance use
• excessive drinking
• fearfulness
• anxiety

• panic attacks
• periods of unusual energy
• trouble sleeping
• not needing sleep
• other, describe below Please enter an 'other' value for this selection. * This question is required.

ROS: EndocrineCheck any of these symptoms that you have had since our last visit.

• trouble tolerating cold
• trouble tolerating heat
• unusual sweating
• tremor

• hair loss
• coarse or croaky voice
• dry skin
• cool skin

ROS: HematologicCheck any of these symptoms that you have had since our last visit.

• anemia

• easy bruising

Check any of these that apply to you

• I need medication refills
• I have had new laboratory studies done since our last visit
• I have had a new medical problem develop since our last visit
• I have had a problem with using alcohol or substances

• Another person has expressed concern about my use of alcohol or substances
• I have had a significant change in financial circumstances
• There is another important issue that we should discuss, please describe below. Please enter an 'other' value for this selection. * This question is required.