Physical Exam Questionnaire

Please correct the errors described below.

Client Information

First name

Last name

Email address

Phone number

Physical exam questionaire

Please check yes if you have any concerns or changes from last year about the following:

Eyes or trouble with vision

Yes No

Ears or trouble with hearing

Yes No

Trouble with chewing or swallowing

Yes No

Chest pains or trouble with heart

Yes No

Lungs or difficulty with breathing

Yes No

Stomach or intestinal problems

Yes No

Pain or other problems with urination

Yes No

Sexual problems

Yes No

Diarrhea or constipation

Yes No

Skin rashes or moles or other problems

Yes No

Mental health - Depression or anxiety

Yes No

Relationship problems

Yes No

Please comment here on any issues you would like to discuss with Dr. Rovner

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