Review of Systems Please indicate any present complaints. Patient Name

Constitutional Symptoms NONE Genitourinary NONE Endocrine NONE Good general health lately No Yes Frequent urination No Yes Glandular or hormone No Yes Recent weight change No Yes Burning or painful No Yes problems Fever No Yes urination Excessive thirst No Yes Fatigue No Yes Incontinence or dribbling No Yes Excessive urination No Yes Kidney stones No Yes Headaches No Yes Hematologic/Lymphatic NONE Male testicle pain No Yes Slow to heal after cut No Yes Eyes NONE Female pelvic pain No Yes Bleeding tendency No Yes Eye disease or injury No Yes Bruising tendency No Yes Wear glasses/contact No Yes Musculoskeletal NONE Anemia No Yes lenses Joint pain No Yes Phlebitis No Yes Blurred or double vision No Yes Joint stiffness or swelling No Yes Past transfusion No Yes Ear/Nose/Throat/Mouth NONE Weakness of muscle or No yes Enlarged glands No Yes joints Hearing loss or ringing No Yes Respiratory NONE Back pain No Yes Earaches or drainage No Yes Cold extremities No Yes Chronic or frequent No Yes Chronic sinus problem No Yes coughs Difficulty in walking No Yes Nose bleeds No Yes Spitting up blood No Yes Muscle pain or cramps No Yes Chronic rhinitis No Yes Shortness of breath No Yes Gout No Yes Mouth sores No Yes Wheezing No Yes Bleeding gums No Yes Integumentary (skin, breast) NONE Bad breath or bad taste No Yes Rash or itching No Yes Allergies NONE Sore throat or voice No Yes Change in skin color No Yes Drug reactions No Yes change Suspicious lesion No Yes Hives No Yes Swollen glands in neck No Yes Seasonal No Yes Cardiovascular NONE Neurological NONE Latex No Yes Heart trouble No Yes Frequent/recurring No Yes Chest pain or angina No Yes headaches Palpitation No Yes Light headed or dizzy No Yes Shortness of breath w/ No Yes Convulsions or seizures No Yes walking or lying flat Numbness/tingling sensa- No Yes Swelling of feet or ankles No Yes tions Tremors No Yes Gastrointestinal NONE Paralysis No Yes Loss of appetite No Yes Head injury No Yes Change in bowel move- No Yes Migraines No Yes ments Nausea or vomiting No Yes Psychiatric NONE Frequent diarrhea No Yes Memory loss No Yes Painful bowel movements No Yes Nervousness No Yes or constipation Depression No Yes Rectal bleeding or blood No Yes in stool Insomnia No Yes Abdominal pain No Yes Confusion No Yes

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform my doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform necessary services I may need. Patient’s Signature: Date (MM/DD/YYYY): / / Physician’s Signature: Date (MM/DD/YYYY): / /

Page 1 of 1 Mountain View Orthopaedics – Scott J. Boyle, D.O. Review of Systems