\\FHFAIRFAX-DC-01\Public\Practice Documents\Physical Exam Form Part I.doc 11/16

Patient: __________________________________ DOB: __________________ Today's Date: _________________

Physical Exam Part I (to be completed by patient): 

Please indicate those items that have been a recurrent problem or recent significant change. Yes No GENERAL SYMPTOMS: good health lately recent significant weight change unusual fatigue or weakness insomnia

EYES: change in vision blurred or double vision eye disease or injury floaters or spots wear glasses / contacts EARS/NOSE/THROAT/NECK: hearing aids hearing loss or ringing in ears earaches or chronic infections chronic sinus problems or runny nose nose bleeds mouth sores bleeding gums sore throat/hoarseness/voice change lumps or swollen glands in neck difficulty swallowing thyroid enlargement/ thyroid disease neck pain or stiffness CARDIOVASCULAR: chest/neck/arm discomfort with exercise palpitations, skipped beats, racing heart shortness of breath: activity rest swelling of feet, legs, ankles, or hands

RESPIRATORY: persistent cough or sputum production coughing or spitting up blood h/o pneumonia, emphysema asthma, history of asthma, wheezing history of smoking > 10 years GASTROINTESTINAL: loss of appetite nausea or vomiting chronic heartburn painful bowel movements/constipation frequent diarrhea rectal bleeding or blood in stools black or tarry stools stomach or abdominal pain increased thirst

Yes No GENITOURINARY frequent urination burning or painful urination blood in urine change in force or stream when urinating incontinence or urine dribbling sexual difficulties Men: testicular pain perform self-testicular exam Women: painful periods irregular periods recurrent vaginal discharge using birth control, method:__________ number of pregnancies__ live births ___ date of last period: _________________

MUSCULOSKELETAL: joint pain joint stiffness/swelling/ or warmth weakness of muscles or joints back pain cold hands or feet difficulty walking

SKIN & BREAST: rashes / itching change in skin color or moles change in hair or nails varicose veins breast pain or lumps or discharge perform monthly self-breast exams NEUROLOGICAL: frequent or recurring headaches light headedness or dizziness convulsions, seizures, or "spells" numbness or tingling sensation tremors or pain in hands and feet balance or gait issues, unexpected falls head injury

MENTAL HEALTH: memory loss or confusion nervousness, anxiety, frequent worries frequent crying spells or mood swings depression/feeling overwhelmed/stressed

SOCIAL HISTORY: currently smoke previously smoked, quit date: ________ consume alcohol, amount per day: _____ regular exercise