Patient Form Submission9. Review of SystemsPlease complete all applicable fields. An asterisk (*) indicates a required field. Name * First Name Last Name Date of birth * MM DD YYYY General fatigue weight loss weight gain Vision blurred vision double vision loss of vision eye discomfort Head and Neck clenching/grinding teeth TMJ pain/discomfort difficulty hearing ringing in the ear(s) ear discomfort hoarseness slurred speech loss of balance nasal discharge Respiratory snoring witnessed pauses in breathing during sleep waking up gasping for air waking up with nasal congestion shortness of breath chest pain cough coughing up blood wheezing Cardiovascular chest pain/pressure short of breath when lying down wake up short of breath sudden passing out irregular heart beat rapid heart beat slow heart rate Gastrointestinal heart burn/reflux abdominal pain difficulty swallowing pain upon swallowing nausea/vomiting vomiting blood bloody/tarry stools constipation diarrhea Genitourinary waking up to urinate blood in urine burning when urinating increased urgency increased frequency wetting the bed/enuresis Endocrine dry mouth increased thirst/drinking increased appetite increased urinary frequency Neurologic headaches seizure activity impaired memory impaired concentration numbness weakness clumsiness tremor Musculoskeletal back pain joint pain joint stiffness neck pain neck stiffness restless sensation in the limbs during the day restless sensation in the limbs at night Mood/Well Being trouble sleeping depressed mood anxiety suicidal thoughts attempts at suicide inappropriate crying inappropriate laughing Hematology/Oncology night sweats unexplained weight loss abnormal bleeding/bruising Thank you!