Review of Systems

Main Complaint (ask also for secondary complaints) Where is it? What is it like? How bad is it (1-10)? When did it start? How long does it last? In what setting does it occur? What makes it better or worse? Are any other symptoms associated with it? OVERALL HEALTH RATING?

Past Medical History Childhood illnesses - Adult Illnesses - Hospitalizations - Surgical Operations - Accidents - Scars on body - Organs removed - Physical or emotional traumas - Psychiatric illnesses - Allergies to drugs, herbs, foods, or other substances.

Social History Living situation - Significant others - Children - Work - Financial stress - Religious beliefs - Outlook on present and future

Skin Color - Temperature - Dry/Moist/Oily - Rash - Hair - Spontaneous sweating during day/night? Other

Head Headaches? Migraine? Fainting? History of head injury or concussion? Other

Eyes Pain? Redness? Blurred vision? Loss of vision (partial/complete)? Last eye exam (glaucoma screen)?

Ears Ringing or other sounds? Dizziness? Pain? Infection? Other?

Mouth and Throat Tongue? Lips? Tonsils? Gums? Mouth ulcers? Strep? Sore throat? Swollen glands? Other?

Upper Respiratory System Phlegm? Sinuses? Allergies? Nose bleeds? Sore throat? Swollen glands?

Lower Respiratory System Cough? Phlegm? Pain? Sounds? Shortness of breath? Blood? Asthma? Bronchitis? Emphysema? Other?

Cardiovascular Hypertension/Hypotension? Chest pain? Heart attack? Stroke? Arrhythmia? Tachycardia? Edema? Varicose veins? Cold extremities? Clotting disorders? Other? Gastrointestinal? Appetite? Food intolerance? Diarrhea? Constipation? Hemorrhoids? Bowel frequency? Stool color and consistency? Bloating? Gas? Belching? Heartburn? Ulcer? Nausea? Vomiting? Mouth ulcers? Mucous/blood in stool? Dysentery? Parasites? Hepatitis? Gall bladder disease? Other?

Urinary system Urinary tract infection? Bladder infection? Kidney infection? Kidney/bladder stones? Water consumption? Urine color? Frequency? Urgency? Nocturia? Hematuria? STD’s? Other?

Reproductive system Female: Last gyn exam? Menarche? Last period? Cycle length? Duration? Regularity? Cramps (before or with flow?) Light/heavy flow? Dysmenorrhea? PMS? Tampons/pads? Sexually active? Frequency? # Partners? Sexually satisfied? Pain during intercourse? STD’s? Contraception? Abortions? Vaginal discharge? Odor? Itching? Cervical cancer? Breast cancer? Miscarriage? Other?

Male: STD’s? Partner with chlamydia? Discharge? Lesions? Testicle pain/tenderness? Prostatitis? Sexually active? Frequency? # partners? Sexually satisfied? Infertility? Impotence? Premature ejaculation (i.e shorter time than you or partner would like)?

Musculoskeletal Pain? Tension? Cramps? Injury? Joint pain? Osteo or rheumatoid? broken bones? Last osteopathic or chiropractic exam?

Nervous Numbness? Tingling? Shooting pains? Paralysis? Dizziness? Seizures? Taste/smell? Memory loss? Stress level?

Endocrine Heat/cold intolerance? Excessive sweating? Dry skin? Thyroid? Fever? Night sweats? Blood sugar (diabetes, hypoglycemia)? Other

Psychological Depression? Thought of suicide? SLAP test (Specific means, Lethal, Available, Proximate)? Anxiety? Irritability? History of physical or sexual abuse (rape?) Mood swings? Addictions? Eating disorder?

Energetics? Pulse (beats per breath)? Pulse (strong/weak)? Pulse (wide/narrow)? Pulse (surface/deep)? Tongue (broad/thin)? Tongue (red/pale)? Tongue coat (heavy, light, none)? Tongue coat (color)