NAME:

MR#:

Ambulatory Services

ADOLESCENT REVIEW OF SYSTEMS BIRTHDATE: Instructions: Check the box for each symptom that the patient has had in the past three months. Fill in the blank spaces.

GENERAL G Pain G Weakness G Stiffness G Fatigue G Weakness G Chills G Twitching G Night sweats G Deformity G Change in weight, appetite or sleeping habits G Chronic back pain EYES G Joint swelling G Glasses or contacts G Decreased range of motion G Blank spots in your field of vision VAGINAL and URINARY (Female) G Excessive tearing or discharge G Vaginal itching or burning G Eye pain G Vaginal discharge G Double vision G Sexually active G Last eye exam, Date: ______G Sexually transmitted diseases (herpes, syphilis, chlamydia, EARS, NOSE, SINUSES, MOUTH and THROAT gonorrhea, AIDS, etc.) G Loss or trouble hearing G Age at menarche: ______G Ringing G Last menstrual period, Date: ______G Drainage G Problems with menstrual periods G Frequent headaches G Last pap smear, Date: ______G Nosebleed G Methods of contraception: ______G Post nasal drip G Pregnancies, number: G Blockage of nose ______G Sinus pain G Problems during pregnancy G Sore throat G Miscarriages or abortions, number: ______G Hoarseness G Pain or frequent urination G Speech problems G Previous urinary tract infections G Bleeding gums G Blood in urine G Teeth problems ______G Kidney stones G Last dental exam, Date: ______GENITAL and URINARY (Male) G Orthodontia G Hernia LUNGS G Discharge from penis G Cough G Pain or lump in testicles G Wheezing G Sexually active G Shortness of breath G Method of contraception: ______G Spitting up blood G Sexually transmitted diseases (herpes, syphilis, chlamydia, G Positive TB Test AIDS, etc.) HEART G Pain or frequent urination G Chest pain G Previous urinary tract infections G Palpitations (heart pounding) G Blood in urine G Trouble breathing at night G Kidney stones G Fatigue easily with exercise HEMATOLOGIC and LYMPHATIC G Ankle swelling G Easy bruising or bleeding problems SKIN G Swollen lymph nodes G Itching ENDOCRINE G Rash G Excessively hot G Change in color G Excessively cold G Changes in warts, moles, or birthmarks G Always thirsty G Acne G Always hungry BREAST NERVOUS SYSTEM G Lumps in breast G Headaches G Discharge from nipple G Numbness GASTROINTESTINAL G Dizziness or passing out G Vomiting G Loss of coordination or balance G Difficulty swallowing G Head injury G Stomach or abdominal pain G Seizures G Indigestion or heartburn PSYCHOLOGICAL G Ulcers G Nervousness/anxiety/stress G Changes in bowel habits G Depression G Blood in stools (or black stools) G Unable to sleep G Nightmares G Rape/partner violence or harassment 3039329 (6/02) Provider Signature ______Date MUSCULOSKELETAL ______