General Fatigue Itching Gastrointestinal No swallowing difficulties,
Weakness hay fever heartburn, change in
Fever nosebleed appetite, anorexia. No Chills stuffiness nausea or vomiting. No weight loss/gain sinus pain change in bowel habits, delay in growth o Mouth bleeding rectal bleeding, change in activity level and sore tongue constipation, diarrhea. No Skin Dryness Throat dry mouth food intolerance. No Lumps dysphagia abdominal pain, bloating Pallor odynophagia or pica. Rashes sore throat Genito-Urinary With enuresis. No Itching hoarseness increased frequency, acne thrush urgency, burning or pain jaundice non-healing sores on urination. No change in hair and nail changes toothache urinary strength, urine HEENT dental carries color or hematuria. No o Head Headache dental check up edema of the hands and Dizziness Neck No lumps, swollen glands, feet. No prepubertal history of head injury pain, stiffness. discharge and itching. o Eyes Redness Breasts No lumps, pain, discharge, Peripheral No calf pain with walking, vision loss or changes discomfort. Vascular leg cramping, stasis use glasses Respiratory With cough, sputum pigmentation. crossed eye production, shortness of Musculoskeletal No muscle or joint pain, pain breath and difficulty of redness, stiffness, back blurring or doubling of breathing. No hemoptysis, pain. No swelling of vision wheezing, painful joints. No weakness. No flashing of lights, specks breathing. history of trauma, dryness Cardiovascular Easy fatigability. No chest limping, limitation of lacrimation pain, discomfort or motion. o Ears decreased hearing tightness. No Neurologic No fainting, seizures, tinnitus palpitations. No weakness, numbness. No earache orthopnea, dyspnea. No tingling sensation, discharge. cyanosis. tremor, paralysis or o Nose Discharge sensory loss. No memory Endocrine Profuse sweating even at Ambulatory, hyposthenic, loss. rest. No heat or cold well-groomed and dressed Psychiatric No trouble sleeping, intolerance. No frequent appropriately for the nervousness, stress. No urination. No polydipsia, weather. depression. No eating polyuria, polyphagia. No Vital Signs Temperature: problems. No personality palpitation. Heart Rate: or behavioral changes, General Survey Conscious Respiratory Rate: temper outbursts, Alert Blood Pressure: hallucinations. Anxious Oxygen Saturation: Hematologic No pallor, jaundice, easy Irritable Anthropometrics Height: bruising, bleeding cardiopulmonary distress, Weight: tendencies. No history of uncooperative, connected BMI: blood transfusions. to an IV fluid line.