Patient Information Form
Part 2 REVIEW OF SYSTEMS

Please print before filling in.
This is a confidential record and will be kept in your doctor's office and will not be released to anyone without your prior authorization.

 

Dr. Domingo E. Galliano Jr.
MD, FACS, FASCRS
University Surgical Associates
GALLIANOSURGERY.COM
18308 Murdock Circle, Suite 108
Port Charlotte, Florida 33948

VOICE - 941.625.3411
FAX - 941.625.1792

email: office@gallianosurgery.com

 

DO YOU NOW OR HAVE YOU HAD ANY PROBLEMS RELATED TO THE FOLLOWING SYSTEMS: (PLEASE EXPLAIN ANY YES ANSWERS IN THE SPACE PROVIDED.)

Please answer: Yes No Please answer: Yes No Please answer: Yes No
CONSTITUTIONAL SYMPTOMS      INTEGUMENTARY SYMPTOMS     ENDOCRINE    
FEVER     SKIN RASH      EXCESSIVE THIRST    
CHILLS     BOILS      TOO HOT/COLD    
HEADACHE     PERSISTENT ITCH     TIRED/SLUGGISH    
OTHER     OTHER     OTHER    
                 
EYES     MUSCULOSKELETAL     RESPIRATORY    
BLURRED VISION     JOINT PAIN     SHORTNESS IN BREATH    
DOUBLE VISION     NECK PAIN     WHEEZING    
PAIN     BACK PAIN     FREQUENT COUGH    
OTHER     OTHER     OTHER    
                 
ALLERGIC/IMMUNOLOGIC      EAR/NOSE/THROAT/MOUTH     HEMATOLOGICAL/LYMPATIC    
HAY FEVER        EAR INFECTION     SWOLLEN GLANDS    
DRUG ALLERGIES     SORE THROAT     BLOOD CLOTS    
OTHER     OTHER     OTHER    
                 
NEUROLOGICAL      GENITOURINARY     CARDIOVASCULAR    
TREMORS      URINARY RETENTION     CHEST PAIN    
DIZZY SPELLS     PAINFUL URINATION     VARICOSE VEINS    
NUMBNESS/TINGLING     URINARY FREQUENCY     HIGH BLOOD PRESSURE    
OTHER     OTHER     OTHER    
                 
GASTROINTESTINAL      PSYCHOLOGIC          
ABDOMINAL PAIN     ARE YOU SATISFIED WITH YOUR LIFE?          
NAUSEA/VOMITING      ARE YOU DEPRESSED?          
INDIGESTION/HEARTBURN     HAVE YOU CONSIDERED SUICIDE?           
OTHER     OTHER