REVIEW OF SYSTEMS FORM NAME: ______DATE______ID______

Do you or have you had any problems related to the following systems? Circle the appropriate response.

(Current) (Past) Explain/give details General History Height Change C P ______Weight Change C P ______Fever/chills C P ______Night sweats C P ______Allergies C P ______Anemia C P ______Bleeding/bruising C P ______Malaise/fatigue C P ______Weakness C P ______Cancer C P ______

Family History Diabetes C P ______Thyroid disease C P ______Tuberculosis C P ______Kidney disease C P ______High blood pressure C P ______Heart disease/stroke C P ______Muscle/joint disease C P ______Cancer C P ______Inflammatory arthritis C P ______Autoimmune disorder C P ______

Cardiovascular System Shortness of breath C P ______Chest discomfort C P ______Calf pain C P ______High blood pressure C P ______Heart disease C P ______Rheumatic Fever C P ______

Respiratory System Difficulty in breathing C P ______Cough C P ______Blood in sputum C P ______Wheezing/asthma C P ______Exposure to chemical/asbestos C P ______Lung Infection/disease C P ______Cigarette/cigar/pipe/chew C P ______

Skin/Hair/Nails Change in skin C P ______Rashes/itching C P ______Skin growths/lesions/cancer C P ______Change in hair quality/growth C P ______Change in nails (finger/toe) C P ______

Endocrine System Heat/cold intolerance C P ______Thyroid Problems C P ______Diabetes C P ______Neck Surgery/Irradiation C P ______Stress C P ______REVIEW OF SYSTEMS FORM NAME: ______DATE______ID______

Eyes/Ears/Nose/Throat Blurred/double vision C P ______Difficulty hearing/deaf C P ______Ringing in ears/dizziness C P ______Ear pain/growth/discharge C P ______Nose bleeds C P ______Change in ability to smell C P ______Nose pain/growth/discharge C P ______Sinusitis C P ______

Gastrointestinal System Change in appetite/food tolerance C P ______Nausea/vomiting C P ______Vomiting of blood C P ______Peptic ulcer C P ______Indigestion/heartburn C P ______Abdominal pain/swelling/gas C P ______Change in stool/color/etc. C P ______Diarrhea/constipation C P ______Hernia C P ______Hemorrhoids C P ______Gallbladder disease C P ______Pancreatitis C P ______

Breast Bumps/lumps/dimples C P ______Pain/tenderness C P ______Change in color/size/shape C P ______Nipple discharge C P ______

Urinary System Frequent urination C P ______Pain on urination C P ______Change in urine/color C P ______Difficulty starting/holding urine C P ______Discharge C P ______Flank/kidney/pelvic pain C P ______Urinary tract infections C P ______Night urination (# of times/night) C P ______

Reproductive System Genital lesions/sores/mass pain C P ______Sexually transmitted infection C P ______Birth control (method) C P ______

Female Patients 1st period______age:______C P ______Flow: Scant/moderate/heavy C P ______Days in cycle C P ______PMS symptoms C P ______First date of last cycle______C P ______Date of last Pap smear C P ______Menopause bleeding/spotting C P ______Post menopause bleeding C P ______# pregnancies___# children C P ______

REVIEW OF SYSTEMS FORM NAME: ______DATE______ID______

Neurologic System Headaches C P ______Seizures/ticks/spasm/tremor C P ______Weakness C P ______Numbness/tingling C P ______Dizzy C P ______

Musculoskeletal System Joint pain/swelling C P ______Muscle cramps C P ______Muscle weakness/wasting C P ______Neck pain C P ______Back pain C P ______Arm pain C P ______Leg pain C P ______Fractures/dislocations C P ______Sprains/strains C P ______Arthritis C P ______Auto-immune disorder C P ______Other accident/injury/disability C P ______

Surgical History Spinal Surgery Yes No______Neck Surgery Yes No______Joint Replacement Yes No______Other Joint Surgery Yes No______Any other Surgery Yes No______

Psychological History Anxiety/nervousness C P ______Psychologic diagnoses C P ______

Medications/Supplements Allergies to medications C P ______Non-prescription medications C P ______Vitamin or Supplement Use C P ______

List prescription medications (continue on back if needed) Purpose for the medication

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I do hereby attest that this information is true, accurate and complete to the best of my knowledge. Patient Signature______Date:______Reviewed By: Intern Signature: ______Date: ______Clinician Signature: ______Date: ______Rev 01/31/14