REVIEW OF SYSTEMS

Revised 10/7/14

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REVIEW OF SYSTEMS

Check ( ) the following conditions

that apply to your health.

Check here if none apply

1. CONSTITUTIONAL

 Chills

 Fatigue

 Fever

 Weight gain

 Weight loss

2. HEENT

 Hearing loss

 Sinus pressure

 Visual changes

3. RESPIRATORY

 Cough

 Shortness of breath

 Wheezing

4. CARDIOVASCULAR

 Chest pain

 Pain while walking (Claudication)

 Edema

 Palpitations

5. GASTROINTESTINAL

 Abdominal pain

 Blood in stool

 Constipation

 Diarrhea

 Heartburn

 Loss of appetite

 Nausea

 Vomiting

6. GENITOURINARY

 Painful urination (Dysuria)

 Excessive amount of urine (Polyuria)

 Urinary frequency

7. METABOLIC/ENDOCRINE

 Cold intolerance

 Heat intolerance

 Excessive thirst (Polydipsia)

 Excessive hunger (Polyphagia)

8. NEUROLOGICAL

 Dizziness

 Extremity numbness

 Extremity weakness

 Headaches

 Seizures

 Tremors

9. PSYCHIATRIC

 Anxiety

 Depression

10. INTEGUMENTARY

 Breast discharge

 Breast lump

 Hives

 Mole change(s)

 Rash

 Skin lesion

11. MUSCULOSKELETAL

 Back pain

 Joint pain

 Joint swelling

 Neck pain

12. HEMATOLOGIC

 Easily bleeds

 Easily bruises

 Lymphedema

 Issues with blood clots

13. IMMUNOLOGIC

 Food allergies

 Seasonal allergies