Review of Systems Update

During the past four weeks, how much have you been bothered by any of the following problems? Please check any of the below problems in the last four weeks or since your last appointment and give brief description of problem.

Constitutional (Description)

Head, Ears, Eyes, Nose, Throat (Description)

Have you been experiencing any abnormal movements? (I.e. face, fingers, feet, mouth)(Required)

Have you thought about or done any of the following? (Description)

Please list any changes in your mood or thoughts.

In a few sentences, please provide an update on how you have been doing and any concerns you have about your mood or medication.(Required)

Please type your full name to electronically sign to the update your review of systems.(Required)

Please select today's date.(Required)

In the event that I am feeling in any way unsafe, unable to predict actions the would jeopardize my safety or the safety of others OR: If I am the parent/guardian of the above named person and believe that they may harm themselves, have harmed themselves, are acting out in ways that jeopardize the safety or themselves OR others – I make pledge and a promise while bering treated by James Geer, that I will talk to the following person, please enter their full name.(Required)

If I am unable to reach this person, I will call 911, I will call Mobile Crisis at: 1-800-652-2929 or I will call the CAPES Unit at Wilmington Hospital: 302-428-2118, Or I will go to the nearest emergency room immediately, please type your full name to electronically sign to the safety contract (parent or guardian).(Required)