Name:______DOB:______
Date:______Sex:______Age:______
General None Yes No Lymph_ None Yes No Pain ▢ ▢ Yes No Fever ▢ ▢ Discharge ▢ ▢ Tender nodes ▢ ▢ Chills ▢ ▢ Other:______Enlargement ▢ ▢ Malaise ▢ ▢ Other:______Fatigue ▢ ▢ Ears None Night sweats ▢ ▢ Yes No Endocrine None Weight changes ▢ ▢ Hearing loss ▢ ▢ Yes No Other:______Pain ▢ ▢ Heat/cold intolerance ▢ ▢ Discharge ▢ ▢ Weight change ▢ ▢ Diet None Vertigo ▢ ▢ Increased thirst ▢ ▢ Yes No Ringing in the ears ▢ ▢ Increased urination ▢ ▢ Appetite ▢ ▢ Other:______Hair changes ▢ ▢ Restrictions ▢ ▢ Other:______Vitamins ▢ ▢ Nose None Supplements ▢ ▢ Yes No Female None Other:______Congestion ▢ ▢ Yes No Nose bleeds ▢ ▢ Changes in menses ▢ ▢ Skin, Hair & Nails None Postnasal drip ▢ ▢ Pain with intercourse ▢ ▢ Yes No Changes in smell ▢ ▢ New partners ▢ ▢ Rash ▢ ▢ Other:______Changes in contraception ▢ ▢ Eruptions ▢ ▢ Menopausal symptoms ▢ ▢ Itching ▢ ▢ Throat & Mouth None LMP______Pigment changes ▢ ▢ Yes No Other:______Hair loss/changes ▢ ▢ Hoarseness ▢ ▢ New moles ▢ ▢ Sore throat ▢ ▢ Male None Lesions /sores ▢ ▢ Bleeding gums ▢ ▢ Yes No Other:______Ulcers ▢ ▢ Puberty onset ▢ ▢ Tooth problems ▢ ▢ Erections ▢ ▢ Head & Neck None Difficulty swallowing ▢ ▢ Testicular pain ▢ ▢ Yes No Changes in voice ▢ ▢ Libido ▢ ▢ Headaches ▢ ▢ Other:______Penile discharge ▢ ▢ Dizziness ▢ ▢ Testicular lumps ▢ ▢ Head injuries ▢ ▢ Gastrointestinal None Difficulty urinating ▢ ▢ Loss of consciousness ▢ ▢ Yes No Other:______Other:______Indigestion ▢ ▢ Heartburn ▢ ▢ Breasts None Eyes None Vomiting ▢ ▢ Yes No Yes No Bowel reg/changes ▢ ▢ Pain ▢ ▢ Blurring ▢ ▢ Nausea ▢ ▢ Tenderness ▢ ▢ Double vision ▢ ▢ Belching ▢ ▢ Lumps ▢ ▢ Glasses ▢ ▢ Flatulence ▢ ▢ Nipple discharge ▢ ▢ Trauma ▢ ▢ Blood in stool ▢ ▢ Skin/pigment changes ▢ ▢ Irritation ▢ ▢ Other:______Other:______Review of Systems continued, pg 2
Name:______
Chest & Lungs None Mental Status No ne Result:______Yes No Yes No Cough ▢ ▢ Loss concentration ▢ ▢ Follow-up:______Sputum ▢ ▢ Difficulty sleeping ▢ ▢ Shortness of breath ▢ ▢ Mood changes ▢ ▢ Other:______Wheezing ▢ ▢ Suicidal thoughts ▢ ▢ Night sweats ▢ ▢ Anxiety ▢ ▢ ______Exposure to TB ▢ ▢ Other:______Other:______Neurological None Cardiovascular None Loss of strength▢ ▢ ______Yes No Tingling/Numbness ▢ ▢ Chest pain ▢ ▢ Headaches ▢ ▢ ______Palpations ▢ ▢ Lightheaded ▢ ▢ Leg or ankle swelling ▢ ▢ Seizures ▢ ▢ Leg pain/cramps Tremors/shaking ▢ ▢ with walking ▢ ▢ Decreased use of limb ▢ ▢ Comments:______Exercise intolerance ▢ ▢ Memory loss ▢ ▢ # of pillows needed to sleep______Confusion ▢ ▢ ______Other:______Other:______Hematology None Health Habits None Yes No Yes No ______Anemia ▢ ▢ Tobacco ▢ ▢ Easy bruising ▢ ▢ Alcohol ▢ ▢ ______Other:______Drugs ▢ ▢ Exercise ▢ ▢ ______Genitourinary None Exposure to chemicals ▢ ▢ Yes No Other:______Pain with urination ▢ ▢ Flank pain ▢ ▢ Health Maintenance None ______Urgency ▢ ▢ Yes No Frequency ▢ ▢ Self exams: Blood in urine ▢ ▢ breast ▢ ▢ Signature: Dribbling/incontinence ▢ ▢ genital ▢ ▢ Getting up at night testicular ▢ ▢ ______to urinate ▢ ▢ # of times______Last PE______Date: Other:______Last pap smear______Musculoskeletal None Last mammogram______Yes No Joint pain ▢ ▢ Diagnostic tests Yes No Heat ▢ ▢ ______Swelling ▢ ▢ Weakness ▢ ▢ ______Loss of coordination ▢ ▢ Loss of mobility ▢ ▢ Date:______Other:______