Review of Systems

Patient Name:______

CONSTITUTIONAL SYMPTOMS MUSCULOSKELETAL Are you in good general health YES NO Joint pain YES NO Recent weight change YES NO Joint stiffness or swelling YES NO Fever YES NO Weakness of muscles or joints YES NO Fatigue YES NO Muscle pain or cramps YES NO Headaches YES NO Back pain YES NO

EYES INTEGUMENTARY Eye disease or injury YES NO Rash or itching YES NO Wear glasses or contacts YES NO Change in skin color YES NO Blurred or double vision YES NO Varicose veins YES NO Glaucoma YES NO Breast lump YES NO Breast discharge YES NO

EARS/NOSE/MOUTH/ ENDOCRINE Hearing loss or ringing YES NO Glandular or hormone problem YES NO Earaches or drainage YES NO Thyroid disease YES NO Chronic sinus problem or rhinitis YES NO Excessive thirst or urination YES NO Nose bleeds YES NO Heat or cold intolerance YES NO Mouth sores YES NO Skin becoming dryer YES NO Bleeding gums YES NO Bad breath or bad YES NO Sore throat or voice change YES NO Swollen glands in neck YES NO Sleep apnea YES NO

CARDIOVASCULAR HEMATOLOGICAL/LYMPHATIC Heart trouble YES NO Slow to heal after cuts YES NO Chest pain or angina pectoris YES NO Bleeding or bruising tendency YES NO Palpitation YES NO Anemia YES NO Shortness of breath YES NO Phlebitis YES NO Swelling of feet, ankles, hands YES NO Past transfusions YES NO

RESPIRATORY GENITOURANARY Chronic or frequent coughs YES NO Frequent urination YES NO Spitting up blood YES NO Burning or painful urination YES NO Asthma YES NO Blood in urine YES NO Change in force/strain of urine YES NO GASTROINTESTINAL Incontinence or dribbling YES NO Loss of appetite YES NO Kidney stones YES NO Change/pain in bowel movements YES NO Sexual difficulty YES NO or YES NO Male-testicle pain YES NO Frequent YES NO Female-pain with periods YES NO YES NO Female-irregular periods YES NO Rectal bleeding or blood in stool YES NO Female-vaginal discharge YES NO or YES NO Female-# of pregnancies YES NO Peptic Ulcer YES NO Female-# of miscarriages YES NO Female – date of last pap smear YES NO PSYCHIATRIC Memory loss or confusion YES NO Nervousness YES NO Depression YES NO Insomnia YES NO Physician’s Initials______