CHECKLIST: Review of Systems
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Dr. Kristin K. Titko
513-729-4455
CHECKLIST: Review of Systems
General- Cardiovascular- Endocrine- Weight loss Cold feet Weight gain □Night cramps Sweating Fatigue □Intermittent claudication Frequent urination Fever or chills Swelling of feet/ankles Thirst Weakness Heart disease Change in appetite Loss of Appetite Diabetes Gastrointestinal- If yes - Type 1 or Type 2 Skin- Indigestion (Dyspepsia) Ulcers Itching (pruritis) Diarrhea Surgical Concerns- Dryness GI bleeding Anesthesia problems Open wounds □Liver disease Wound healing Nail changes/fungus problems Rashes Vascular- Calf Pain with walking Please check if you are Respiratory- Leg cramping being treated for any Shortness□ of breath of the following: COPD Psychiatric- Thyroid Painful breathing Nervousness Osteopenia Asthma Stress Drug abuse Cough Depression COPD Memory loss AIDS/HIV Musculoskeletal □ Hepatitis□ -Joint/muscleJoint/muscle stiffnessstiffness Neurologic- Alcoholism Back pain burning in feet/legs □Alzheimer’s Redness of joints Seizures Blood Clots where? Swelling of joints Unsteady gait Cancer where? Osteoarthritis Tremors High Cholesterol Gout Dizziness □Diabetes Rheumatoid Arthritis Fainting High Blood Pressure Muscle or joint pain Tingling in feet/legs CVA/Stroke Numbness in feet/legs ⎕ Kidney Disease Hematologic- Weakness in feet/legs ⎕Take Blood Thinner
Ease of bleeding Current weight?______Ease of bruising Current height?______List Other Medical Conditions:
I do not have any of the above conditions
Patient’s Name: ______Patient Signature:______Date: ______